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Am Fam Physician. 2000;62(9):2105

Pediatricians manage fever in their patients in a variety of ways. One increasingly common practice is to alternate acetaminophen and ibuprofen. It is unclear whether this practice is a response to parental or physician anxiety about fever. Mayoral and colleagues developed a questionnaire to determine how widespread this practice is and whether it has any scientific basis.

Physicians attending professional meetings were asked to fill out a questionnaire about fever instructions, at which temperature antipyretics were initiated and how they were administered. A MEDLINE search found no scientific data relating to the safe administration of acetaminophen and ibuprofen.

One hundred sixty-one surveys were completed. More than one half of the physicians (62 percent) reported starting antipyretic therapy at 38.3°C (101°F) although some (11 percent) recommend starting treatment at 38°C (100.5°F). About one third of physicians recommend a dosage of 10 mg per kg of acetaminophen every four hours; one third recommend using 15 mg per kg every four hours. An ibuprofen dosage of 10 mg per kg every six hours was recommended by 22 percent and 8 percent recommended 7.5 mg per kg every six hours. One half of physicians recommended alternating acetaminophen and ibuprofen, although the method for alternation varied. Almost one half of physicians recommended acetaminophen every four hours and ibuprofen every six hours. Some recommended alternating the two drugs every two or three hours. About one third of physicians reported following American Academy of Pediatric (AAP) recommendations, although the AAP has made no such recommendations.

The authors caution against recommending an alternating regimen of antipyretics to parents for their children for several reasons. First, there is no evidence that such a regimen is safe. Second, there is no evidence that a more rapid decrease in fever is achieved or that the alternating combination is more efficacious than either agent used alone. Finally, and perhaps most importantly, the “alternating antipyretic” instructions for parents may be confusing (if alternating every four and six hours, which drug is given at the 12th hour?) and may lead to an overdose of one of these medications. Until further studies are done, the most judicious advice to parents with a febrile child is to use one antipyretic agent or the other, not an alternating combination.

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