By Laurence Degelsmith, MD
October 5, 2007
I’ve been an emergency physician for ten years and I’m constantly reminded that parents and patients are often confused about the difference between acetaminophen (Tylenol) and ibuprofen (Motrin, Advil).
They are both very useful medications for fevers and pain and are generally very safe when given at prescribed doses. They work differently in the body to control fever and pain and therefore have some different properties and potential side effects as well as toxicities. In this article, I will discuss my preferences for when to give which medication.
Tylenol
I’ll begin with Tylenol, since I believe it is the more commonly used medication with children. Tylenol comes in various forms (liquid, pills, capsules, suppositories and chewable). Regardless of which preparation is used, the dose to give a child is always based on the weight of the child and not the age. Many Tylenol preparations suggest an approximate dose based on the child’s age but it is important to know his or her weight, since it’s very easy to under dose a child and therefore fail to control the fever.
I can’t think of any contraindication to giving Tylenol except for known liver disease or allergy to the medication. Tylenol is a great medication since it can be given to patients of any age, child, infant or even newborn. There is a very high safety margin with Tylenol which means that it takes a lot of medication to cause an overdose. In fact, you would have to give close to seven times the normal dose to be at risk of causing liver damage, which is the main concern with Tylenol overdosing.
The typical recommended dose of Tylenol is 10-15 mg per kilogram—or 7 mg per pound. (We use metric in the hospital and most dosing is referred to in mg per kilogram or mg/kg.) Tylenol can be given safely at this dose every four hours for 1-2 weeks without a concern for liver damage. It is also considered safe to take Tylenol with just about any other medication a child might be taking. The maximum daily dose of Tylenol is 90 mg/kg/day for children. Because the safety margin is so high, you don’t have to be exact when dosing a child. In fact, there are several studies that advocate giving a double dose of Tylenol (20-30 mg/kg) one time every couple of days for high fevers and this is often done in hospital emergency departments.
The possibility of a Tylenol overdose causing liver damage is certainly a serious concern but it is hard to do unintentionally. Occasionally a child or adult takes too many pills to help control a fever or painful condition and an overdose can occur—but this is when a handful of pills is ingested rather than the prescribed amount. Keep in mind that most drugs are dangerous when 7-10 times the recommended dose is taken. It is also very important to remember that many over-the-counter cold medications contain Tylenol so you need know how much Tylenol a child might already be taking in with various other medications. I believe that this is how most unintentional overdoses occur. *
Ibuprofen
Ibuprofen—better known as Motrin or Advil (different companies but identical drug)—is also a very safe medication. Ibuprofen is actually the safest NSAID (non-steroidal anti-inflammatory drug) on the market with the fewest side effects. Ibuprofen comes in liquid, pills, chew tabs, gels and capsules but not suppositories. It can be given to infants as young as 2 months of age and can also be given around the clock for 1-2 weeks at the recommended dose without worrying about toxicity.
The recommended dose for ibuprofen is 5-10 mg/kg or 4.5 mg/lb every six hours, but we usually stick to 10 mg/kg in the emergency department. We don’t, however, give a double dose to control stubborn fevers—as we sometimes do with Tylenol—since a double dose of ibuprofen is no better than a standard dose in controlling fevers. Ibuprofen can cause stomach pain so it’s often given with food but that’s not a necessity. The maximum daily dose of ibuprofen is around 40 mg/kg/day. Caution should be used when a child has a known liver or kidney ailment (disease) or if the child suffers from gastritis or has a stomach ulcer which can be exacerbated by ibuprofen.
Acetaminophen and ibuprofen are both great for fevers as well as mild-to-moderate pain. Most emergency physicians prefer ibuprofen to bring down fevers in the emergency department since it brings the fever down faster and lasts a bit longer. It also tends to bring down the fever further than acetaminophen. And, unlike acetaminophen, ibuprofen is also an anti-inflammatory and therefore better controls pain associated with inflammation. Some conditions involving inflammation where I prefer ibuprofen are: sore throats, ear pain, muscle or joint injuries and bee stings. Although Tylenol can also be used effectively for these maladies, I prefer ibuprofen.
Finally, when treating a stubborn fever in a child lasting several days, I recommend alternating the Tylenol and Motrin (or Advil) so that you give one medication followed by the other in three hours. In this way the child is receiving an antipyretic (fever reducing agent) every three hours but alternating the different medications decreases any risk of toxicity.
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* An obvious or suspected ingestion of too much Tylenol should be seen in the emergency department immediately since we can prevent liver toxicity if caught early enough (within a day). A Tylenol overdose initially causes nausea/vomiting and abdominal pain followed by an asymptomatic period in a day or so, which is accompanied by elevation in the liver enzymes. After 3 days is when the liver starts to essentially die and you would see signs of liver failure, which can only be treated by a liver transplant.
Laurence Degelsmith graduated from Horace Greeley High School in 1985, has an undergraduate degree from Washington University in Saint Louis, attended New York Medical College and did his residency in emergency medicine at the University of Michigan. He is an emergency department physician at Northern Westchester Hospital in Mt. Kisco and a member of the Chappaqua Volunteer Ambulance Corps.
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