Search tips
Search criteria 


Logo of canfamphysLink to Publisher's site
Can Fam Physician. 2010 August; 56(8): 773.
PMCID: PMC2920778

Treatment of pediatric fever

Are acetaminophen and ibuprofen equivalent?
G. Michael Allan, MD CCFP
Associate Professor in the Department of Family Medicine at the University of Alberta in Edmonton and the Medical Director of Toward Optimized Practice
Noah Ivers, MD CCFP
Family physician at Women’s College Hospital in Toronto, Ont

Clinical question

Is acetaminophen or ibuprofen superior for the treatment of pediatric fever?


A meta-analysis and recent randomized controlled trial provide some guidance.

  • Meta-analysis of 10 trials (N = 1078) of ibuprofen (5 to 10 mg/kg) versus acetaminophen (10 to 15 mg/kg)1:
    • -ibuprofen was superior at 2, 4, and 6 hours; and
    • -at 4 to 6 hours, approximately 15% more ibuprofen patients had fever reduction (number needed to treat = 7).
  • PITCH randomized controlled trial (N = 156, aged 6 months to 6 years) comparing ibuprofen (10 mg/kg every 6 to 8 hours), acetaminophen (15 mg/kg every 4 to 6 hours), or a combination of both2:
    • -For time without fever in the first 4 hours, the combination was superior to acetaminophen by 55.3 minutes (P < .001) but was not superior to ibuprofen.
    • -Ibuprofen and the combination cleared fever faster.
    • -The combination reduced fever time in the first 24 hours (acetaminophen 4.4 hours more [P < .001], ibuprofen 2.5 hours more [P = .008]).
    • -Overdose was reported in 33 children (21%).
    • -The authors recommended ibuprofen:
      • —ibuprofen was superior to acetaminophen;
      • —the combination was only slightly better on a few outcomes than ibuprofen alone; and
      • —there was a possible risk of excess dosing with the combination.


Some debate surrounds the use of antipyretics:

  • There is no evidence that fever itself is harmful (theorized that it might be part of the immune response).3
  • Antipyretics do not seem to prevent febrile seizures.4
  • There is no evidence that treating fever in mild infections is harmful (unless overdosed).
  • If fever is treated, the goal should likely be comfort5 (although no studies have investigated comfort in fever).

Adverse effects of ibuprofen compared with acetaminophen:

  • asthma—no increased risk or perhaps slightly lower6 (possible slight increase with acetaminophen2);
  • Reye syndrome—no increased risk7,8;
  • gastrointestinal and renal effects—no evidence of risk,9 but the Canadian Paediatric Society advises against ibuprofen if a child is not “drinking reasonably well”5; and
  • systemic reaction—no evidence of risk.7

Bottom line

The appropriateness of treating pediatric fever is controversial and should be discussed with parents. If clinicians are going to recommend a treatment, they should know that ibuprofen offers superior fever reduction with no increase in adverse events.


Providing pamphlets about fever management can reduce parental anxiety and decrease emergency visits.10 Although the evidence for patient information leaflets is generally poor,11 pamphlets about pediatric infections seem to work if they are reviewed during the clinical encounter.12 Therefore, reviewing the Canadian Paediatric Society handout5 with parents to explain fever management might be helpful, but the pamphlet could be altered to encourage ibuprofen use with appropriate dosing regimens.


Tools for Practice articles in Canadian Family Physician are adapted from articles published twice monthly on the Alberta College of Family Physicians (ACFP) web-site, summarizing medical evidence with a focus on topical issues and practice-modifying information. The ACFP summaries and the series in Canadian Family Physician are coordinated by Dr G. Michael Allan, and the summaries are co-authored by at least 1 practising family physician. Feedback is welcome and can be sent to ac.cpfc@ecitcarprofsloot. Archived articles are available on the ACFP website:


The opinions expressed in this Tools for Practice article are those of the authors and do not necessarily mirror the perspective and policy of the Alberta College of Family Physicians.


1. Perrott DA, Piira T, Goodenough B, Champion GD. Efficacy and safety of acetaminophen vs ibuprofen for treating children’s pain or fever: a meta-analysis. Arch Pediatr Adolesc Med. 2004;158(6):521–6. [PubMed]
2. Hay AD, Costelloe C, Redmond NM, Montgomery AA, Fletcher M, Hollinghurst S, et al. Paracetamol plus ibuprofen for the treatment of fever in children (PITCH): randomised controlled trial. BMJ. 2008;337:a1302. Erratum in: BMJ 2009;339:b3295. [PubMed]
3. Mackowiak PA. Physiological rationale for suppression of fever. Clin Infect Dis. 2000;31(Suppl 5):S185–9. [PubMed]
4. Steering Committee on Quality Improvement and Management, Subcommittee on Febrile Seizures Febrile seizures: clinical practice guideline for the long-term management of the child with simple febrile seizures. Pediatrics. 2008;121(6):1281–6. [PubMed]
5. Caring for kids [website] Fever and temperature taking. Ottawa, ON: Canadian Paediatric Society; 2009. Available from: Accessed 2010 Jun 21.
6. Kanabar D, Dale S, Rawat M. A review of ibuprofen and acetaminophen use in febrile children and the occurrence of asthma-related symptoms. Clin Ther. 2007;29(12):2716–23. [PubMed]
7. Southey ER, Soares-Weiser K, Kleijnen J. Systematic review and meta-analysis of the clinical safety and tolerability of ibuprofen compared with paracetamol in paediatric pain and fever. Curr Med Res Opin. 2009;25(9):2207–22. [PubMed]
8. Lesko SM, Mitchell AA. The safety of acetaminophen and ibuprofen among children younger than two years old. Pediatrics. 1999;104(4):e39. [PubMed]
9. Lesko SM, Mitchell AA. An assessment of the safety of pediatric ibuprofen. A practitioner-based randomized clinical trial. JAMA. 1995;273(12):929–33. [PubMed]
10. O’Neill-Murphy K, Liebman M, Barnsteiner JH. Fever education: does it reduce parent fever anxiety? Pediatr Emerg Care. 2001;17(1):47–51. [PubMed]
11. Nicolson D, Knapp P, Raynor DK, Spoor P. Written information about individual medicines for consumers. Cochrane Database Syst Rev. 2009;(2):CD002104. [PubMed]
12. Francis NA, Butler CC, Hood K, Simpson S, Wood F, Nuttall J. Effect of using an interactive booklet about childhood respiratory tract infections in primary care consultations on reconsulting and antibiotic prescribing: a cluster randomised controlled trial. BMJ. 2009;339:b2885. [PubMed]

Articles from Canadian Family Physician are provided here courtesy of College of Family Physicians of Canada