Ibuprofen (Ibugesic) is the Preferred Antipyretic for Pediatric Fever
Ibuprofen should be the first-line antipyretic for fever management in children over 3 months of age, as it demonstrates superior antipyretic efficacy compared to paracetamol (acetaminophen), particularly for bacterial infections, with a longer duration of action requiring less frequent dosing. 1
Evidence Supporting Ibuprofen as First-Line
Superior Efficacy Profile
- Ibuprofen has been shown to be more effective than paracetamol as an antipyretic in comparative clinical trials, with maximum temperature reduction occurring 3-4 hours after administration 2
- The effective dose range is 7.5-10 mg/kg, with ibuprofen demonstrating at least equal analgesic efficacy and superior antipyretic efficacy compared to paracetamol 3
- Ibuprofen provides longer duration of action (6-8 hours) versus paracetamol (4 hours), reducing dosing frequency and improving compliance 3
Dosing Recommendations
- Standard dosing: 5-10 mg/kg per dose, administered 3-4 times daily 4
- Maximum total daily dose: 30-40 mg/kg 4
- Ibuprofen should be prescribed based on body weight, not age alone 4
Critical Safety Considerations and Contraindications
Absolute Contraindications for Ibuprofen
- Dehydration or risk of dehydration (diarrhea, vomiting, poor oral intake) - this is the most important contraindication 5, 6
- Neonates (under 3 months of age) 6
- Body weight below 5-6 kg 4
- Active varicella (chickenpox) infection - increased risk of invasive group A streptococcal infection 5, 6
- Wheezing or persistent asthma 6
- Known hypersensitivity to NSAIDs 6
When to Use Paracetamol Instead
Switch to paracetamol (10-15 mg/kg every 4-6 hours, maximum 5 doses in 24 hours) in the following situations: 7
- Any signs of dehydration (dry lips, decreased urine output, poor oral intake)
- Gastroenteritis with vomiting or diarrhea
- Children under 3 months of age
- Chickenpox infection
- Compromised renal function or fluid status 7
Important Clinical Caveats
Hydration Status is Critical
- Special attention must be given to hydration status before and during ibuprofen use - dehydration plays an important role in triggering acute renal failure 4, 6
- Ibuprofen should never be administered to patients with diarrhea and vomiting, with or without fever 6
Avoid Rectal Administration
- The rectal route shows erratic absorption, especially in young infants, and is less reliable than oral administration 4
Overdose Safety Profile
- Ibuprofen is safer in overdose than paracetamol - paracetamol toxicity is reached much earlier, is more severe, and more difficult to manage 2, 3
- Paracetamol hepatotoxicity can occur at doses only slightly above therapeutic levels 7
Mefenamic Acid (Meftal) - Not Recommended
Mefenamic acid is not mentioned in any major pediatric fever management guidelines and lacks the extensive safety and efficacy data that exist for ibuprofen in children. The absence of guideline support and limited pediatric evidence makes it an inappropriate choice when superior alternatives exist.
Key Pitfalls to Avoid
- Do not use ibuprofen as routine antipyretic for simple fever - it should be reserved for inflammatory pain or when paracetamol is contraindicated 6
- Never alternate ibuprofen with other antipyretics - this increases risk of dosing errors and toxicity without proven benefit 7
- Aspirin must be avoided in children under 16 years due to Reye's syndrome risk 7
- Antipyretics do not prevent febrile seizures and should not be prescribed for this purpose 7
Clinical Algorithm
- Assess hydration status first - if any concern for dehydration, use paracetamol instead 6
- For well-hydrated children >3 months with fever: Use ibuprofen 5-10 mg/kg every 6-8 hours 4, 3
- For children <3 months, dehydrated, or with contraindications: Use paracetamol 10-15 mg/kg every 4-6 hours 7
- Encourage adequate fluid intake regardless of antipyretic choice 7
- Focus on treating underlying infection rather than fever itself - fever reduction is for comfort only 1