Annika got her first fever over Christmas. It went up to 105.8° F (on a temporal artery thermometer).

I can just hear the other parents now: “Yikes! 105.8? You gave her Tylenol, right?”

Nope. No Tylenol, no ibuprofen, nothing but extra cuddles and lots of nursing.

Her fever broke on its own a few hours later, and the next morning she was crawling around fast as her little buns could take her.

It’s not unusual for children to have very high fevers. In fact, it is generally very helpful for kids to get robust fevers, as it signals a strong immune response which can quickly eliminate pathogens (the bad bugs). A fever isn’t intrinsically dangerous until it reaches 108° F (yikes that is high!), as that is the point at which brain damage can occur.

Febrile (fever) seizures can occur at temperatures below this point. Despite the fact that they are unbelievably scary, febrile seizures alone are not a reason to give Tylenol or other fever-reducers. In fact, febrile seizures in otherwise normal children are completely safe. (Except that they may raise the parent’s blood pressure!)

Many parents mistakenly give their children fever-reducing agents thinking that it is the best thing for their child.  In fact, many parents give Tylenol before their child has a fever!  Remember that it is not considered a fever until the temperature reaches greater than 100.4° F with a rectal, ear or temporal thermometer, or greater than 100° F with an oral thermometer.  (Rectal, ear and temporal thermometers are generally about a degree higher than oral thermometers.  That’s why the 105.8 degree temporal reading didn’t worry me as much.) Anything under that reading is considered a normal variation in body temperature.


Here are some guidelines for managing a high fever:

  1. Pay more attention to how the child is looking/feeling than what the thermometer says.  A really sick looking kid is really sick, no matter what the temperature (high or low!).  Sometimes kids will get listless, stop crying, and cannot be stimulated.  Other times they will be incredibly irritable and cry uncontrollably.  Use your best Mom (or Dad) radar and follow your instincts!
  2. Normal fevers are between 100 and 104° F.  I want to hear from you if the child’s fever is higher than that.  Often times it will be just like Annika’s story and we can wait it out, but once in a blue moon a dangerous situation can arise suddenly.
  3. Wait on the Tylenol. The brain has a set-point at which fever tops out – it is totally a myth that without treatment a fever will keep rising indefinitely.  Another myth: breaking the fever will stop the infection.  In fact, the cytokines that cause fever also signal the immune system to do its job – we don’t want to interfere with that process!
  4. AGAIN – how your child looks is the most important determinant of whether your child has a serious infection.  Repeat after me: “It is not the number, but how my child looks that is important”.
  5. All that said: it is NEVER normal for a newborn to have a fever.  Any infant under age 3 months with a fever (greater than 100.4° F) needs to be checked out.

Any why does Dr. Erika not like Tylenol?  Oh this is a favorite subject of mine.  I promise to devote an entire muckraking article to why I loathe acetaminophen (no fault to the makers of Tylenol, they’re just doing their job), but here is the simplified version:

Acetaminophen is hugely liver toxic.  And I don’t mean in a vague, naturopathic “oh that McDonald’s hamburger is bad for your liver”.  Acetaminophen is the number 1 cause of liver failure in the UK, and the number 2 cause in the US (of cases requiring liver transplantation).  It is more common than viral hepatitis leading to acute (sudden) liver failure.

Why? The liver converts acetaminophen into N-acetyl-p-benzoquinone imine (NAPQI) in an attempt to get rid of it. (“N-acetyl what??” Don’t worry about pronouncing it, there will be no test at the end of this blog).  The problem is that NAPQI requires huge amounts of a really important endogenous (body-made) antioxidant called glutathione in order to make it less toxic.  Glutathione is responsible for scavenging all the free radicals produced all over the body by various (often normal!) metabolic processes.  NAPQI chews up glutathione in massive quantities, leaving excess free radicals to burn and cause DNA and cellular damage all over the body.  The liver then has to deal with not only the lack of glutathione, but the highly toxic NAPQI.  Hepatocellular (liver cell) damage, necrosis (ugly cell death), and liver failure follows.

The super rad chemical structure and how it is converted in the body (for all you nerds out there). Paracetamol is just another name for acetaminophen.

The super rad chemical structure and how it is converted in the body (for all you nerds out there). Paracetamol is just another name for acetaminophen. GSH in an abbreviation for glutathione (the purple arrow). The blue arrows show other pathways the liver can use for detoxification too.

Okay, so you’ve taken Tylenol in the past and you didn’t die, so no harm, no foul, right?  Sort of.  The liver is an incredibly resilient organ, so in most normal people it takes the hit, waits until the acetaminophen passes, restores glutathione (if you eat right) and then rebuilds liver cells.  BUT, in small children, in anyone with liver damage, or in large doses it can lead to liver failure.

Acetaminophen has a much lower maximum daily dose than almost any other over the counter medication.  Adults should take NO MORE than 3,000 mg per day.  That is six 500-mg pills per day.  Children’s dose is at maximum 80 mg/kg per day.  Most people have no idea what that means, which is why pediatricians give you a dosing chart.  Do NOT exceed that dose!! The problem is that acetaminophen is in many combination products, including over the counter cough syrups, Nyquil, pain formulas and more.  Read the labels carefully!

I have more reasons to loathe acetaminophen, including the implications of depleting glutathione in developing children.  I’ll write a much more in depth post about that in the future, including why I think acetaminophen use may be related to autism.

Until then, here’s your review:

  1. It’s not the degree of fever, but how your child looks that matters.
  2. Avoid acetaminophen whenever possible.  When you do use it, read the label carefully and never exceed the recommended amount.  Check all your pain, flu and fever combination products for their active ingredients, and never combine Tylenol with other over-the-counter formulas.

Don’t believe me? Here’s a great article from Seattle Children’s Hospital about the Myths of Fever.

And here is another great post, written by my colleague, about how to overcome your Fever Phobia.


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13 Responses

  • Hi Dr. Erika

    Thank you for breaking down the fever phobia myth so eloquently. It is a shame how our knee jerk reaction is to lessen a fever at first sight, even to preemptively treat it. There is always a time and place for medications that suppress symptoms, but should not be the standard of care. The body is doing an amazing job at not only increasing the temperature so pathogens can’t live, but increasing the body’s immune response. We shouldn’t get in the way of that process unless absolutely necessary!

  • Bridget Grusecki says:

    Love your website and blog!
    I am with you on respecting the wisdom of the body when it comes to safe fevers, and I am wary of acetaminophen in particular as well. I am interested in the theory that lowering fevers prolongs illness or impairs the immune system. I’ve looked for data on this, and unfortunately, there isn’t a lot out there. Here is a blurb from one article that questions the risk-benefit profile on antipyretics (with a link to the full article below).

    “Moreover, the relative cost of such symptomatic relief, in terms of drug toxicity and adverse effects of antipyretic agents on the course of the illness responsible for the fever, has never been determined. The importance of such information is underscored by reports that acetaminophen prolongs the time to crusting of skin lesions in children with chicken pox95 and that acetaminophen and aspirin increase viral shedding and nasal signs and symptoms while suppressing the serum-neutralizing antibody response in adults with rhinovirus infections.96- 97 Findings of studies in human volunteers imply further that the capacity of antipyretic agents to prolong the course of rhinovirus and varicella infections might extend to viruses such as influenza virus as well (K.I.P., S. Kudaravalli, MD, S. S. Wasserman, MD, and P.A.M., unpublished data, 1999).”
    Plaisance KI, Mackowiak PA (2000) Antipyretic therapy: physiologic rationale, diagnostic implications, and clinical consequences. Archives of Internal Medicine, 160, 449–456.

    • Hi Kate,

      Personally, I would go for ibuprofen before Tylenol, but I know some pediatricians strongly disagree. Ibuprofen carries the risk of kidney damage (though usually in long-term, chronic use). It seems that Dr. Sears agrees with me, though, and goes for Ibuprofen first, since it has less risk of fatal overdose.

      I think the point is to avoid pain relievers whenever humanly possible, then to use the minimum dose possible. I prefer to alternate Tylenol with Ibuprofen to minimize the “hit” on any one system.

      It’s always worth a shot to try some natural methods first – it’s amazing how a little bit of Chamomile or Lemon balm tea will calm a baby down and reduce their fever. And these are much safer!

  • Beatrice Bernardez says:

    Acetaminophen is used to treat many conditions such as headache, muscle aches, arthritis, backache, toothaches, colds, and fevers.’;-;

    Newly released article straight from our very own blog page

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  • Kelia says:

    Hi, Dr. Erika, I just read your article. My daughter is 3 year old, and my pediatrician recommends when is over 100F underarm, then take the Tylenol and if 1 hr the temperature doesn’t drop, take Motrin. I just realized from your article that Tylenol is so harmful for the liver. She was at 103.6F and she had felt tired and slept most of the day, so before she went to bed at night, i gave her a dosage of Tylenol, then she fell asleep and Woke up in 4am, i checked her temperature, is about 100.4F, but i think she acted ok, so I did not give her medication. I always confused during this point, should I continuing giving her the medicine? and right now i heard from you the Tylenol is bad, is that the same as Advil or Motrin? Should I give Motrin to her directly to replace Tylenol? Sorry I am a first time mother, hope you can help clarify. thanks!

    • Hi Kelia,

      I know this is a late response, I apologize.

      Normal fevers are not harmful. I don’t usually recommend giving a child anything for a fever unless they are very uncomfortable or the fever is very high (over 104). Of course, I am not your child’s physician, so there may be another reason why your pediatrician recommends Tylenol. I don’t like baby Ibuprofen either, but if necessary I usually have parents alternate Tylenol and baby Ibuprofen. I recommend checking out the link from Seattle Children’s Hospital on fevers – bring that article to your pediatrician’s office and ask what their recommendation is.

  • Helo dr.erika,

    Thank you for such an informative article about fever’s synopsis.. i wanted to ask you that i’ve been takin acetaminophen for 3 days but my fever is not going down my fever constantly stuck at 100 to 102 deg F.please would you recommend sth more natural n effective way to ward off my fever down.

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