Fever and pain in children between paracetamol and ibuprofen

Paracetamol and ibuprofen are the only antipyretic drugs recommended for pediatric age. Their administration is indicated when fever causes discomfort to the child. A recent meta-analysis showed that discontinued usage of these drugs cannot prevent fever convulsions.[1] Their usage is indicated also from mild to moderate pain treatment.
Both drugs can induce renal, hepatic and gastrointestinal adverse reactions.

Fever treatment

In clinical practice, ibuprofen is sometimes administered both in combination both alternated to paracetamol, whenever this last one alone appears to be not effective in relieving the symptom of fever. A literature systematic review showed that combining paracetamol with ibuprofen is not more effective in controlling fever than the single drugs.[2] Studies conducted until now are small and span over a too short time period to detect possible adverse reactions. Besides, they have been designed to simply monitor the fever decrease and not to ascertain relief from the discomfort it causes.
The alternated use of these drugs has not been demonstrated to be more effective in controlling fever than the single drugs either.[3] Reports of adverse renal, hepatic and gastrointestinal reactions linked to the combined or alternated use of ibuprofen with paracetamol are constantly increasing.
Under hypovolemic conditions, also the alternated use of paracetamol with ibuprofen can cause hepatic, renal and gastrointestinal adverse reactions, even at therapeutic dosage.[4] A Cochrane systematic review, still at protocol phase, has now been started with the aim of verifying by meta-analysis the efficacy and safety of combined or alternated use of paracetamol and ibuprofen for fever treatment.[5]
Nowadays, combined or alternated usage of paracetamol and ibuprofen are not recommended anymore by the most recent guidelines on fever management in pediatric age.[3]

Pain treatment

A literature systematic review on a total of 378 children showed that the combined use of paracetamol and ibuprofen is more effective than the single drugs in the acute post-surgery pain treatment, with not serious adverse effects. However, the authors underline that the combined use of these drugs can increase the risk of adverse reactions, especially when administered at fixed doses without any flexibility.[6] In clinical practice, then, when mild-moderate pain is not sufficiently relieved by paracetamol alone, the analgesic power should be first increased by substituting the paracetamol with ibuprofen or with paracetamol-codeine,[7] before considering their association.
However, when moderate pain is not sufficiently controlled, it is advisable to combine paracetamol (± codeine) with ibuprofen only for short period, leaving only the paracetamol (± codeine) for the long term and administering the other drug (usually ibuprofen) when necessary.

In practice

When treating fever in pediatric age, the combined or alternated use of paracetamol and ibuprofen is not sufficiently effective to justify the risks linked to their potential toxicity, especially when the child is scarcely hydrated. The combined use of these medicines is up today advisable only when mild-moderate pain treatment is not controlled by the single drugs alone, always allowing a certain amount of flexibility in the second drug administration, usually ibuprofen, because fixed-doses could increase the toxicity risk.