The Trouble with Tylenol
By Erica Zelfand

Why I don’t recommend Paracetamol for most families.

If you’ve ever walked into a pharmacy or raised a child, chances are you’ve heard of Paracetamol, Acetaminophen, or Tylenol.

These are all the same drug, actually. In the United States and Canada, the generic drug is known as Acetaminophen, and is commonly sold under the brand name Tylenol. In the rest of the world, the drug is known as Paracetamol.

No matter what you call it, this drug can be a powerful medicine or a serious health risk. It all depends on how you use it, how often, and in whom. Let’s explore the pros and the cons of this drug, and why it’s likely that you’re over-using it on yourself and your kids.

Tylenol’s limits in infection & inflammation:

Many parents reach for the Paracetamol when their kiddos start complaining of body aches, fever, or other signs of the flu (influenza), COVID, or other infectious illness. That’s because the medication reduces fever, and also decreases pain – though not as well as Ibuprofen does.

It’s important to know that Tylenol will do absolutely nothing to help your child fight the infection or recover faster. Also, Acetaminophen does not significantly reduce inflammation, so it won’t do much to help with swelling. (Again, Ibuprofen is the better choice for fighting inflammation – more on that later.)

The only point of Paracetamol is to keep your kiddo more comfortable while they’re sick. This can not only spare a child from suffering, but also help them get a good night’s sleep. Indeed, the whole family can benefit from Paracetamol, because when a kid with the flu can’t sleep, usually it keeps up the adults in the house too. A night of good sleep is priceless!

While no parent wants to see their child struggle with the discomfort of a fever or the associated headaches and body aches, Paracetamol comes with risks. Tylenol could actually make it harder for the child’s immune system to fight the infection, in taking their body a longer time to recover. This means more sick days.

Acetaminophen can do harm in the following ways:

1. Tylenol blocks antioxidant function

Tylenol inhibits the body’s production of a very important antioxidant known as glutathione. [1,2] (In fact, glutathione can be used to treat cases of Paracetamol-induced liver poisoning! [3])

The antioxidant function of glutathione supports many types of body’s immune cells, in turn helping the body identify and eliminate harmful bacteria, viruses, and fungi. Glutathione also helps the body recycle vitamin C and E, other important agents in helping the immune system overcome sickness [4]. Low glutathione levels, in turn, weaken the immune system, making it harder for the body to fight infections [5]. Taking Acetaminophen can reduce glutathione levels, in turn making it harder for the body to overcome infections [6]. The Acetaminophen can have the exact opposite effect as we might desire!

2. Acetaminophen can hurt the liver

In most people, taking no more than the recommended dose of Acetaminophen is typically safe. The difference between a safe dose and a dangerous dose, however, is very small. In medicine, this is known as a “narrow therapeutic window.” Typically, drugs with a narrow therapeutic window are not available over-the-counter, but rather require a doctor’s prescription to purchase. Many pharmacists agree that if Paracetamol was invented today, that it would be a prescription-only drug.[7]

Just a few extra pills per day can make the difference between a healthy pain relief and acute liver toxicity.[8] No other drug causes more liver failure than Paracetamol. [9,10,11]  Acetaminophen-related liver toxicity is responsible for about half of all cases of acute liver failure in the United States. [12] Acetaminophen toxicity is the #1 reason for liver transplants in the USA, and the #2 reason for liver transplants worldwide. [13]

In summary: Paracetamol is mean to the liver, and it doesn’t take much more than the recommended dose to cause major harm.

3. Paracetamol slows the immune system

Many people appreciate the anti-pyretic (fever-reducing) properties of Paracetamol. In general, people in the Western world have become very fever-phobic, which is not a good thing. [14,15] Fever is an important part of how the body kills bacteria, viruses, and fungi. Without a sufficient fever, harmful microbes stay alive and active in our bodies, making us sicker for longer.

When I was in medical school, one of my mentors would joke, “Would you rather cook a turkey on high heat for 10 hours, or on low heat for a whole week? It’s the same with infections!” In my medical practice, I see that the children who take Paracetamol get sick much more frequently than the kids whose parents don’t give them fever-reducing drugs. When I myself get sick, I find that I recover much more quickly if I let the fever do its job. 

A 2019 review concludes that the scientific evidence does not support giving fever-reducing medication to children with infections like influenza. [16] It’s important to know what’s causing a fever in a child – once it’s clear that it’s influenza, Covid-19, or other common pediatric virus, the best bet is to leave it alone, and intervene only if it reaches about 104 degrees Fahrenheit (40 Celsius).   

Although febrile seizures can terrify parents, they’re actually normal, and they do not cause brain damage, speech delays, or other long term issues. Many parents are reassured to know that a fever can only cause brain damage if it goes about 108 degrees F (42.22°C). [17] To better understand the value of fevers, check out this page from Seattle Children’s Hospital, and check out my post on “Fever? Flu? Congratulations!

Note: It is never normal for a newborn baby to have a fever – this warrants immediate medical attention.)

What’s a Parent to Do?

As with everything in medicine (and life), things aren’t black-and-white. Paracetamol is neither 100% safe nor 100% dangerous. Rather, it’s important for parents to weigh the risks and benefits. In general, most households are over-using Paracetamol and likely need to cut back on its use.

Here are some general guidelines for helping you use the Acetaminophen only when it’s truly needed, and to reduce the risks of harm:

1. Take the recommended dose (or less).

Taking more than the recommended dose of Tylenol can cause significant damage to the liver. Remember: Acetaminophen is the #1 cause of acute liver failure in the developed world! Stick with the recommended dosage.

2. Never let children dose their own Paracetamol.

Because of the very narrow therapeutic window of this drug, a sober adult should always be the one overseeing administration of Paracetamol. Don’t let big kids and teenagers take the bottle to their room or decide when or how much to take without your supervision.

When dosing children, be sure to consult a pediatric dosing calculator such as this one. The dosage of Acetaminophen for children is determined by their body weight, and is much lower than what is safe for adults.

3. Supplement with antioxidants.

Easy-to-find options include vitamin C, a cup of fresh berries, a cup of organic green tea, or some melatonin. Melatonin in particular is a powerful antioxidant that can help both kids and adults get a good night’s sleep.

When you reach for the Acetaminophen, be sure to grab some antioxidants too!

4. Trust the fever.

Be brave! Let the body fight that infection quickly and effectively, and leave the fever-reducing drugs on the shelf.

5. Use other remedies to stay comfortable.

Use the warming sheet wrap and warming sock remedies. Try magnesium, chamomile tea, mullein, and lavender herbal products.

6. Try ibuprofen.

Many parents and pediatricians believe the (outdated) advice that kids should only have Paracetamol and never Ibuprofen. While Ibuprofen and other NSAID drugs come with their risks, a recent review on children and fevers concludes that “Current evidence suggests that there is no substantial difference in the safety and effectiveness of acetaminophen and ibuprofen in the care of a generally healthy child with fever.” [18]

Another review of 19 studies showed that for children of under two years of age, Paracetamol and Ibuprofen came with comparable risks: One drug wasn’t found to be any safer than the other. [19] This was echoed by a study of Nigerian children under the age of five. [20] Yet another meta-analysis and qualitative review of clinical studies concludes: “Ibuprofen is as or more efficacious than acetaminophen for the treatment of pain and fever in adult and pediatric populations and is equally safe.” [21]

Ibuprofen, furthermore, is anti-inflammatory and can therefore reduce swelling much more effectively than Paracetamol. It also doesn’t harm glutathione production, and only very rarely causes serious liver problems. [22] Ibuprofen can, however, cause digestive and kidney troubles with regular, long-term use. [23]

Note: Avoid giving Aspirin to a child or teenager with a fever caused by a virus. When used in this context, Aspirin has been linked to a very serious condition known as Reye’s Syndrome. Associated with brain swelling and liver degeneration, Reye’s Syndrome can be life-threatening. Thankfully, it is also very rare – but let’s not take our chances! [24]

And remember: Children are strong!

The average child’s immune system works much better than the average adult’s. Once it’s clear that a kiddo isn’t sick with something life-threatening, our job is usually to give them love and marvel at how amazing their bodies are at healing themselves.