Using Ibuprofen and Acetaminophen Together: A Pharmacist Explains
Remember the infamous 2023 "tripledemic" of RSV, Flu, & COVID? I sure do. My 15-month-old baby got walloped by RSV and then also tested positive for COVID during our SECOND trip to urgent care in 2 days.
We worked through a whole host of breathing problems, but he also had a high fever that wouldn't quit! That's not his picture above, but that's pretty much what he looked like for seven days.
What is a Fever?
A fever is an elevation in core body temperature. A temperature greater than 100.4°F (38°C) is classified as a fever.
Infection is the most common cause of fever, although it could be from overheating (especially in newborns), vaccines, certain medical conditions, or sometimes for an unknown reason.
Fever doesn't always require treatment in children. In healthy kids older than 3 months, you can feel reasonably confident that a fever is OK if they're otherwise comfortable and able to drink water. It's a sign that the body is fighting off an infection and can help the immune response.
Fever is usually urgent in babies younger than 3 months, and your child should be evaluated promptly.
See your doctor for fever if your child is immunocompromised, has cancer or other medical conditions, has a central line or port, has a prolonged fever with unknown cause, has a rash, has symptoms suggestive of another problem like urinary tract infection or strep throat, or appears very ill (dehydrated, extreme lethargy, etc).
A fever should be treated in healthy children when it's causing too much pain for your child to drink, eat, and rest comfortably. When my baby was struggling with RSV and COVID, he had a fever of 102-103°F for days.
We used fever-reducing techniques and medications to help him get comfortable, which in turn slowed down his work of breathing and helped him drink fluids. This particular fever was super stubborn, so in consultation with the pediatrician, I elected to alternate between acetaminophen and ibuprofen.
Treatment of Pain in Children
Pain can occur for many reasons. Along with fever, acetaminophen and ibuprofen are also used to treat mild to moderate pain.
Sports injuries, headaches, the flu, and minor bumps and bruises may be reasons your child needs an over-the-counter pain reliever. Both medications help to relieve pain. Ibuprofen is often the preferred first choice for pain management because it also reduces inflammation.
Severe pain, pain after a head injury or other serious accident, or pain that lasts should not be self-treated and needs a healthcare provider's attention.
What are OTC Pain and Fever-Reducing Medications?
Fever-reducing medications, or antipyretics, reduce a patient's body temperature. Several drugs can do this, but the two most commonly used are acetaminophen (Tylenol®) and ibuprofen (Motrin®). They are available over the counter in various formulations, such as liquid, tablets, and chew tabs.
Acetaminophen also comes in suppositories, which can be very helpful for babies or children who cannot tolerate oral medications.
Acetaminophen can be used in babies as young as 3 months old and ibuprofen in babies as young as 6 months old.
Please contact your doctor for guidance for babies under those ages. Your doctor may, for example, recommend acetaminophen in a baby under 3 months of age, but only after an examination and under their guidance.
Acetaminophen and ibuprofen also relieve pain, which can be a bonus for sick kids. Many illnesses, such as the flu, can cause fever, headache, and aches and pains, so a drug that serves dual purposes can be beneficial.
Pain from minor injuries, menstrual cramps, teething, or other childhood bumps and bruises can also be treated with acetaminophen and ibuprofen. Always consult your pediatrician for severe or persistent pain or pain after a significant injury.
I keep acetaminophen and ibuprofen liquid bottles and chew tabs in my house at all times (stored safely, of course!). While fever is not usually dangerous, you never know when you'll need a dose with kids. Running out to the drugstore at 11 p.m. or on a holiday is never fun.
As a side note, over the years, I have found that vacations and holidays seem to be excellent times for children to get sick! I've never seen a study on this theory, but I'm willing to bet that many parents would agree...
Why Alternate Acetaminophen and Ibuprofen
Acetaminophen and ibuprofen are in different drug classes. They work in different ways and are metabolized in different ways, meaning it is OK to use them together when pain and fever relief from one agent isn't enough.
A disclaimer here is that it's OK to use them together for short periods only. If your child needs either drug for several days, reach out to your doctor. Ibuprofen can only be used in patients older than 6 months of age.
Having both drugs available gives parents more tools to fight off fever. For example, if acetaminophen doesn't get your child comfortable enough, parents can provide ibuprofen in the hopes that both drugs combined will do the job. This is known as dual therapy.
Alternate therapy, or alternating between the two drugs, allows parents to treat with medicine more often because they can alternate agents if more treatment is needed but the first medicine isn't due yet.
For example, acetaminophen at 7 AM, ibuprofen at 10 AM, acetaminophen again at 1 PM, etc. This allows for more around-the-clock coverage.
You can also strategically plan around meals or bedtime. Ibuprofen lasts a bit longer, so I like to use it in the evening, hoping my children will sleep comfortably just a bit longer. Rest is essential for overcoming infections!
Additionally, ibuprofen is best given with food, while acetaminophen is OK on an empty stomach. Therefore, acetaminophen is usually my drug of choice for overnight wake-ups. Staggering the two options around mealtimes gives you flexibility for optimal comfort.
How do you use Acetaminophen and Ibuprofen Together?
The biggest tip for using acetaminophen and ibuprofen is to write down the dose and time each medicine is given. Acetaminophen can be given every 4-6 hours, and ibuprofen every 6-8 hours. It's easy to mix them up, so jot it down!
If your child has been given a dose of one medication and is still febrile or uncomfortable, you can provide the dose of the other medicine. Then, follow the due times of each drug, giving each as recommended.
Please remember to treat the child, not the clock. If your kiddo is resting comfortably, you don't necessarily have to give acetaminophen or ibuprofen just because the time is up (unless your doctor recommends giving it "scheduled" or around the clock!)
An example of alternating acetaminophen and ibuprofen might look something like this:
5 AM: The child awakens, is very fussy and febrile, and can't settle. Give acetaminophen.
7 AM: The child is still febrile and uncomfortable and won't eat or drink. Give ibuprofen.
11 AM: The child woke up from nap febrile again. It's too soon for ibuprofen, but it's been 6 hours since the last acetaminophen dose, so offer that.
And so on! Write down each dose and keep the optimal time intervals in mind. Do not give more than five doses of acetaminophen or four doses of ibuprofen in one 24-hour period. Consider providing ibuprofen with meals, as it's better tolerated with food in the tummy.
What are the Risks?
The most significant risk of using ibuprofen and acetaminophen together is accidentally giving the wrong drug at the wrong time. This could lead to an accidental overdose.
If you choose to use acetaminophen and ibuprofen in conjunction with one another, I do recommend writing the times down! When your kid(s) are sick, and you're sleep-deprived and feeling run down, it's easy to mix the two drugs up.
Secondly, there is no conclusive evidence that using these drugs together is better than just picking one and sticking with that. The American Academy of Pediatrics (AAP) does not endorse dual or alternate antipyretic therapy.
A recent analysis suggests that using the two drugs together may be more effective than using acetaminophen alone, but it's likely as effective as using ibuprofen alone. The side effect profile of single or dual/alternate therapy is similar.
Many healthcare providers agree that dual/alternate treatment can be helpful. Still, there is a real risk of mix-ups and confusion. Talk with your doctor to clarify whether alternating medicines is right for you.
Additional Safety Tips
In general, acetaminophen and ibuprofen are well tolerated and have low-risk profiles. Speak with your pediatrician before use if your child has any problems with their kidneys, liver, or heart. Additionally, discuss with your doctor whether your child is taking any other regular medications.
Avoid using combination drugs like "cold and flu" medications. These aren't usually intended for kids, and they often contain acetaminophen or ibuprofen as one of their active ingredients, so use caution to prevent accidentally giving too much!
Conclusion
In conclusion, acetaminophen and ibuprofen can be helpful tools for managing stubborn fever or moderate discomfort. You can use them alone or together. It's beneficial to write down the times that your child receives a medication so that you can follow the recommended dosing schedules.
Talk to your child's doctor if you have questions about whether this therapy is right for you.
References
The following references were used to compile this information:
American Academy of Pediatrics. (n.d.). Acetaminophen for fever and pain. HealthyChildren.org. https://www.healthychildren.org/English/safety-prevention/at-home/medication-safety/Pages/Acetaminophen-for-Fever-and-Pain.aspx
American Academy of Pediatrics. (n.d.). Fever and your baby. HealthyChildren.org. https://www.healthychildren.org/English/health-issues/conditions/fever/Pages/Fever-and-Your-Baby.aspx
American Academy of Pediatrics. (n.d.). Fever without fear. HealthyChildren.org. https://www.healthychildren.org/English/health-issues/conditions/fever/Pages/Fever-Without-Fear.aspx
American Academy of Pediatrics. (n.d.). Ibuprofen for fever and pain. HealthyChildren.org. https://www.healthychildren.org/English/safety-prevention/at-home/medication-safety/Pages/Ibuprofen-for-Fever-and-Pain.aspx
De la Cruz-Mena, J. E., Veroniki, A. A., Acosta-Reyes, J., Estupiñán-Bohorquez, A., Ibarra, J. A., Pana, M. C., Sierra, J. M., & Florez, I. D. (2024). Short-term Dual Therapy or Mono Therapy With Acetaminophen and Ibuprofen for Fever: A Network Meta-Analysis. Pediatrics, 154(4), e2023065390. https://doi.org/10.1542/peds.2023-065390
KidsHealth. (n.d.). Fever. The Nemours Foundation. https://kidshealth.org/en/parents/fever.html
