It’s 2am, your child is wailing because she has a fever, and you’re staring at the medicine cabinet, wondering what will make her feel better and let both of you get to sleep sooner rather than later.  Sound familiar?

Non-pharmaceutical options for making her feel better is the topic of another blog.  Today I will discuss the pros and cons of the 2 major pain relivers/fever reducers in children: acetaminophen (e.g.Tylenol) and ibuprofen (e.g. Motrin, Advil.)  Aspirin, even baby aspirin, is not used in children because of its association with Reye’s Syndrome.  Reye’s Syndrome is the profound liver failure and brain swelling seen in children who received aspirin during a viral illness, especially chicken pox and influenza.  It is almost unheard of anymore since warnings against the use of aspirin in children appeared.

Tylenol and similar products are the only fever reducers licensed for children less than 6 months.  It is processed by the liver which makes it safer in kids with kidney problems or dehydration.  It is not associated with stomach irritation or ulcers.  It is available as a suppository so febrile kids who are vomiting can still receive it.

The down sides of acetaminophen are potential liver toxicity and concerns about its association with asthma. Too much acetaminophen, whether from too big a dose, a correct dose given too often or getting it from more than one source (e.g. regular Tylenol plus Tylenol Cold and Flu) damages the liver; in extreme cases permanently and irreparably. If the overdose is discovered early, it can be treated with an antidote called N-acetylcysteine, but almost always requires admission to the hospital.

Dr John McBride, a pulmonary specialist at Akron Children’s Hospital (and one my residency mentors) published an article in the December issue of Pediatrics outlining studies that showed that children who received more doses of acetaminophen had more asthma.  Whether the acetaminophen caused (or at least exacerbated) the asthma or whether kids with asthma are just sicker and more likely to have a febrile illness is not clear.  Still, Dr McBride recommends avoiding it, especially in high risk children, until the question is answered definitively.

Ibuprofen has the advantage of being an anti-inflammatory in addition to an analgesic (pain reliever) and fever reducer.  Probably for that reason, ibuprofen was shown to be superior to both acetaminophen and Tylenol with codeine in reducing the pain associated with broken bones.  A dose of ibuprofen tends to last longer (on average 6-8 hours) than an equivalent dose of acetaminophen (4-6 hours).

Ibuprofen cannot be used for kids less than 6 months of age because it can be toxic to their kidneys. It has also been known to cause kidney damage or even failure when given to dehydrated children.  It can cause stomach irritation (which is reduced when taken with food) and, if taken for a long period of time, stomach ulcers.  Rarely, people who are allergic to aspirin are also allergic to ibuprofen.  It is not commercially available as a suppository although some pharmacies will compound it for you.

So, which to choose?  In general, I tell people to use the one that is already in front of them.  Acetaminophen is really the only choice if the child is less than 6 months old.  I don’t recommend the use of ibuprofen in children with vomiting and/or diarrhea or who are drinking poorly.  Ibuprofen lasts longer, so that is a bonus at night.  Ibuprofen is superior for bone pain like fractures. I think the data for asthmatic children are too limited to make a strong recommendation against acetaminophen, but it would something to consider if there is a strong family history of asthma.

If you have questions about your specific child, ask his regular health provider for guidance.  And use caution when determining the correct dose for your infant.  In an attempt to limit confusion and avoid overdoses, the traditional “Infant’s Tylenol”, which is more concentrated than “Children’s Tylenol”, is being pulled from the market.  However, old packages remain, both in stores and in homes.  In addition, there are packages of “Infant Fever Reducer” available which have the new concentration of acetaminophen.  Read the package carefully, especially the drug concentration, and don’t hesitate to ask if you are unsure.

Here’s to some restful sleep!