What is the preferred medication for fever in a toddler over 2, ibuprofen or acetaminophen?

Preferred Medication for Fever in Toddlers Over 2 Years Old

Ibuprofen is generally more effective than acetaminophen for fever control in toddlers over 2 years of age, particularly for maintaining temperature reduction over longer periods.

Comparative Efficacy of Ibuprofen vs. Acetaminophen

Temperature Reduction

• Ibuprofen (5-10 mg/kg) demonstrates superior fever reduction compared to acetaminophen (10-15 mg/kg) at 2,4, and 6 hours after administration 1
• The temperature-reducing effect of ibuprofen is more pronounced and longer-lasting:
  • At 2 hours: Effect size 0.19 (95% CI, 0.05-0.33)
  • At 4 hours: Effect size 0.31 (95% CI, 0.19-0.44)
  • At 6 hours: Effect size 0.33 (95% CI, 0.19-0.47) 1
• More recent evidence confirms ibuprofen's superior antipyretic effect in children under 2 years, which extends to older toddlers 2

Pain Relief

• For pain management, both medications show comparable efficacy at standard dosing 1
• However, ibuprofen may provide better pain relief at 4-24 hours after administration (SMD, 0.20; 95% CI, 0.03-0.37) 2

Dosing Recommendations

Ibuprofen

• Recommended dose: 5-10 mg/kg per dose
• Administration interval: Every 6-8 hours (maximum of 3 doses in 24 hours) 3, 4

Acetaminophen

• Recommended dose: 10-15 mg/kg per dose
• Administration interval: Every 4-6 hours (maximum of 4 doses in 24 hours) 4

Safety Considerations

Ibuprofen Cautions

• Should be avoided during chickenpox due to increased risk of invasive group A streptococcal infections 5
• Not recommended when there's risk of dehydration due to potential renal effects 5
• Should not be used in patients taking aspirin for antiplatelet effects 3

Acetaminophen Cautions

• Risk of hepatotoxicity with overdose 6
• May cause methemoglobinemia when used concurrently with certain medications 6

Safety Profile Comparison

• Both medications have similar safety profiles when used at recommended doses 1, 2
• Serious adverse events are uncommon with both medications (odds ratio for ibuprofen vs. acetaminophen: 1.08; 95% CI, 0.87-1.33) 2

Special Considerations

Alternating Therapy

• Some evidence suggests that alternating acetaminophen and ibuprofen (every 4 hours) may provide better fever control than either medication alone 7
• However, this approach increases the risk of dosing errors and potential overdose 4
• If using both medications, careful recording of all dose times is essential 4

Febrile Seizures

• Neither ibuprofen nor acetaminophen has been shown to prevent febrile seizures 6, 3
• The American Academy of Pediatrics notes that antipyretics do not prevent recurrence of febrile seizures 6, 3

Practical Recommendation

For fever control in toddlers over 2 years old:

1. Start with ibuprofen (5-10 mg/kg) as first-line therapy due to its superior and longer-lasting antipyretic effect
2. Use acetaminophen as an alternative when:
   • The child has chickenpox
   • There is risk of dehydration
   • The child is taking medications that might interact with ibuprofen
   • The child has a history of adverse reactions to ibuprofen

Remember that fever itself is generally a protective response and not harmful. Treatment should focus on improving the child's comfort rather than normalizing temperature.