What is the recommended dose of paracetamol (acetaminophen) syrup for children?

Paracetamol (Acetaminophen) Syrup Dosing for Children

The recommended dose of paracetamol syrup for children is 10-15 mg/kg per dose, given every 4-6 hours, with a maximum daily dose of 60 mg/kg per day (not to exceed 5 doses in 24 hours). 1

Standard Dosing by Age and Weight

The FDA-approved dosing guidelines provide the following age-based recommendations for paracetamol syrup 2:

• Children 2 to under 4 years: 5 mL (160 mg) every 4 hours, not to exceed 5 doses in 24 hours 2
• Children 4 to under 6 years: 7.5 mL (240 mg) every 4 hours, not to exceed 5 doses in 24 hours 2
• Children 6 to under 12 years: 10.15 mL (325 mg) every 4 hours, not to exceed 5 doses in 24 hours 2
• Children under 2 years: Consult a doctor 2

Weight-Based Dosing Approach

For optimal efficacy, use 15 mg/kg per dose rather than 10 mg/kg, as recent evidence demonstrates significantly better pain and fever control at this higher dose. 3 The 15 mg/kg dose is as effective as NSAIDs while maintaining the safety profile of placebo. 3

Practical Weight-Based Calculation:

• Calculate the child's weight in kg
• Multiply by 15 mg/kg for each dose
• Administer every 4-6 hours as needed 1
• Never exceed 60 mg/kg per day total 1

Special Populations

Infants Under 3 Months:

• Paracetamol is the only recommended analgesic for this age group 1
• Use 15 mg/kg per dose if weight is less than 10 kg 1
• Consult physician before administering 2

Infants 3-8 Months:

• Dose: 3 mg/kg per dose twice daily for treatment 4
• Not recommended for prophylaxis in infants under 3 months unless situation is critical 4

Administration Guidelines

Use an appropriate measuring device such as a 3-mL or 5-mL oral syringe for accurate measurement to prevent dosing errors. 5 Kitchen spoons are unreliable and should never be used.

Route Considerations:

• Oral syrup is strongly preferred over rectal suppositories because it is absorbed more rapidly and provides more consistent response 1, 6
• Rectal administration has erratic absorption and should only be used when the child is actively vomiting or in perioperative situations where oral intake is restricted 1

Critical Safety Warnings

Maximum Dose Limits:

• Never exceed 60 mg/kg per day 1
• Never give more than 5 doses in 24 hours 1, 2
• Chronic exposures greater than 140 mg/kg/day for several days carry risk of serious hepatotoxicity 7
• Single ingestions of more than ten times the recommended dose are potentially toxic 7

Common Pitfalls to Avoid:

• Do not use subtherapeutic doses of ≤10 mg/kg, as older studies using these doses showed inferior efficacy compared to NSAIDs 3
• Do not confuse different formulation concentrations when calculating doses
• Do not combine multiple paracetamol-containing products (many cold/flu medications contain paracetamol)

When to Consider Alternative or Additional Treatment

If paracetamol at 15 mg/kg is ineffective for fever management, ibuprofen may be considered as second-line treatment. 5 When alternating medications, give paracetamol every 4-6 hours and ibuprofen every 6-8 hours, staggering timing so medications are given every 3-4 hours if both are needed. 1

Special Clinical Scenarios

Post-Vaccination Fever:

• Can be given at time of vaccination and every 4 hours for 24 hours 1

Febrile Seizure History:

• Prophylactic dose of 15 mg/kg every 4 hours for 24 hours can reduce fever risk, though it does not prevent febrile seizures themselves 1

Severe Pain:

• Paracetamol alone is appropriate only for mild-to-moderate pain 1
• For severe pain, it offers significant additive analgesic effect when combined with opiates 7