WHY THIS MATTERS
Fever is one of the most common reasons parents bring a child to the hospital. Doctors often recommend paracetamol (called acetaminophen in the U.S.), ibuprofen, or sometimes both. But does combining or alternating these medicines really work better than using one alone?
WHAT IS FEVER?
Fever is a body temperature above the normal range. It can occur due to brain lesions, heatstroke, strenuous exercise, anemia (low red blood cells), or toxins that disrupt the body’s temperature regulation.
PYROGENS: THE TRIGGERS BEHIND FEVER
A pyrogen is a substance that raises the body’s “thermostat” in the hypothalamus. Pyrogens may come from bacteria (such as endotoxins from gram-negative bacteria), proteins, or breakdown products of tissues.
In simple terms: pyrogens trick the brain into thinking the body is colder than it really is, causing the temperature set-point to rise.
HOW ENDOTOXINS RAISE TEMPERATURE
When bacteria or their fragments are ingested by white blood cells or macrophages, these immune cells release interleukin-1 (IL-1), also called endogenous pyrogen. IL-1 triggers the production of prostaglandin E2 (PGE2) in the hypothalamus, which resets the body’s temperature upward.
PROSTAGLANDINS: LOCAL HORMONE MESSENGERS
Prostaglandins are fatty acid derivatives that act locally and are rapidly broken down. They belong to a group called autacoids, which function like local hormones but do not circulate widely in the blood.
In simple terms: prostaglandins are the chemical messengers that signal the brain to raise body temperature.
HOW PROSTAGLANDINS ARE MADE
Cell membranes release arachidonic acid through the enzyme phospholipase A2. Arachidonic acid is then converted to prostaglandins by cyclo-oxygenase (COX-1 and COX-2) enzymes.
non-steroidal anti-inflammatory drugs (NSAIDs) like ibuprofen block COX enzymes, stopping prostaglandin production. This lowers fever, reduces inflammation, and relieves pain.
PARACETAMOL VS. IBUPROFEN
Paracetamol/Acetaminophen lowers fever mainly by reducing prostaglandin levels in the brain. Its exact mechanism isn’t fully understood. It works as an antipyretic (fever-reducing) and mild analgesic (pain-relieving) but has no anti-inflammatory effect.
Ibuprofen blocks prostaglandin production throughout the body. It acts as an antipyretic, analgesic, and anti-inflammatory agent, making it helpful when inflammation is present.
SHOULD THEY BE COMBINED OR ALTERNATED FOR FEVER?
Some hospitals now recommend alternating or combining paracetamol and ibuprofen for children with fever. Although both medicines can be given together without direct harm, clinical studies show no added benefit over using one drug alone.
BEST PRACTICE:
• Use single-drug therapy first (either acetaminophen or ibuprofen).
• Keep the child hydrated, dress in light clothing, and use cool compresses.
• Avoid using both medicines for more than 48 hours without medical advice.
Combination therapy may be considered if the child is very uncomfortable, refuses fluids, or if fever remains high despite single drug use, but this decision should be made with a healthcare professional.
PAIN RELIEF: WHEN COMBINATION HELPS
For pain with inflammation such as injuries or post-surgical discomfort alternating or combining paracetamol and ibuprofen can provide better relief than one medicine alone, because ibuprofen adds an anti-inflammatory effect that paracetamol lacks.
PHARMACIST’S PERSPECTIVE
As a pharmacist, the priority is safety and precise dosing:
• Weight-based dosing is essential.
1. Acetaminophen: 10–15 mg/kg every 4–6 hours (max 5 doses or 75 mg/kg in 24 hours; do not exceed 4,000 mg/day).
2. Ibuprofen: 5–10 mg/kg every 6–8 hours (max 40 mg/kg in 24 hours).
• Use liquid formulations with calibrated syringes for accuracy. Household spoons are unreliable.
• Monitor total daily acetaminophen intake carefully to avoid accidental overdose, especially if using combination cough/cold products that may also contain it.
• For infants under 6 months, acetaminophen is generally preferred; ibuprofen is not recommended without medical supervision because of kidney and stomach risks.
U.S. GUIDELINE HIGHLIGHTS
The American Academy of Pediatrics (AAP) and the Centers for Disease Control and Prevention (CDC) advise:
• Treat fever for comfort, not to chase a specific number.
• Either acetaminophen or ibuprofen can be used for most children over 6 months, following weight based dosing.
• Alternating or combining is not routinely recommended, as it complicates dosing and increases the risk of errors, though it may be used short-term under professional guidance for distressing fevers.
KEY TAKEAWAYS
• Fever itself is usually not harmful; focus on the child’s comfort and hydration.
• Single-drug therapy is preferred for routine fever in children.
• Combination or alternating therapy should be short-term and supervised by a healthcare professional.
• Accurate weight-based dosing and careful measurement are critical to prevent overdose.
FAQs
Q1. Can I give paracetamol and ibuprofen together to my child for fever?
Yes, they can be given together if recommended by a healthcare professional, but U.S. guidelines generally suggest using one medication at a time first. Combination therapy is not routinely necessary.
Q2. How often can I alternate paracetamol and ibuprofen in children?
If alternating is advised by a doctor, give paracetamol every 4–6 hours and ibuprofen every 6–8 hours, without exceeding the daily maximum dose of each.
Q3. Which is better for children’s fever paracetamol or ibuprofen?
Both are effective for reducing fever. Paracetamol is preferred for mild fever and pain, while ibuprofen also helps with inflammation. Use the one your child tolerates best.
Q4. Are there risks of giving ibuprofen to children?
Yes. Ibuprofen may irritate the stomach or kidneys, especially if the child is dehydrated. Always give it with food or milk and ensure proper hydration.
Q5. When should I call a doctor for a child’s fever?
Seek medical advice if the child is younger than 3 months with a temperature of 100.4°F (38°C) or higher, if fever lasts more than 3 days, or if there are signs of dehydration or serious illness.
DISCLAIMER
This content is for educational purposes only and is not a substitute for professional medical advice. Always consult a healthcare provider before giving paracetamol (acetaminophen) or ibuprofen to a child.
CALL-TO-ACTION
Always check with your child’s pediatrician or pharmacist before using paracetamol or ibuprofen especially for infants or children with underlying health conditions. Safe dosing matters more than quick relief.
REFERENCES
• American Academy of Pediatrics. Clinical Report: Fever and Antipyretic Use in Children, Pediatrics, 2021.
• Centers for Disease Control and Prevention (CDC). Treating Fever in Children, updated 2023.
• World Health Organization. Pocket Book of Hospital Care for Children, 2nd edition, 2022. • National Institute for Health and Care Excellence (NICE). Fever in Under 5s, 2021.