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Ask Dr. Sue
COUGH MEDICINES
Dear Dr. Sue,
The last time I took my child in for a bad cold, my
pediatrician was unwilling to give me the prescription
cough medicine we have always gotten before. I
don’t understand why we can no longer use that, since it
helps his bad cough. Now I don’t have anything to
do for his cold. Also, I don’t like him coughing
in everyone’s face; I’m trying to keep the rest of the
family from getting sick. What is best to give him
for his cough, and for his runny nose, too?
Dear Parent,
Evidence has been accumulating for several years now
that cough and cold preparations, whether prescription
or over-the-counter, do not offer any benefit to
children, and do come with a risk of significant side
effects.
The prescription cough syrup you are referring to is
likely to have contained codeine. Repeated studies
have failed to show that codeine has any effect at all
on children’s coughs. Codeine may suppress cough
in adults by acting on the cough center in the brain.
It is cleared from the body through the liver, and this
clearance can be affected by other medications your
child might be given (including acetaminophen and many
prescription medications) which would further increase
the risk of side effects. Codeine may cause
dizziness, drowsiness, vomiting, rashes or itching.
In the worst case scenarios it can cause a decrease in
or total loss of the drive to keep breathing.
There have been several reported deaths in children
related to codeine use. (1)
So should you turn to over-the-counter medications to
help your child’s cough? The American College of
Chest Physicians says definitely not (2) and the
American Academy of Pediatrics agrees with them.
Once again, when all of the studies done so far were
analyzed, none of these medications actually offered any
true relief of children’s cold symptoms, and all had
potential risks.
Dextromethorphan is a compound that was derived from
narcotics. It, too, acts on the cough center in
the brain to decrease cough. It has no addictive
potential, but carries a similar risk of decreased
respiratory drive. It has also been associated
with extreme agitation, loss of balance, abnormal
movements of the arms and legs, and even coma. (3)
Guaifenesin is an expectorant, and expectorants have not
been found to actually affect cough or secretions, even
in adults.
Many over-the-counter cough preparations include either
antihistamines or decongestants, or both. Histamine is a
chemical that is released during an allergic reaction;
it is not involved in the symptoms of a cold.
Antihistamines may act to thicken secretions, which may
mean fewer nose wipes, but may make breathing through
the nose more difficult. Antihistamines can cause
increased heart rate, blurred vision, agitation,
hyperactivity, psychotic behavior and seizures.
Decongestants have become increasingly difficult to get
at your local pharmacy or grocery store. First the
decongestant pseudoephedrine was restricted because it
is used in methamphetamine production. Most
recently, the Food and Drug Administration advised that
phenylpropanolamine, another very commonly used
decongestant, be removed from all products because it
may cause an increased risk of strokes.(4)
Decongestants also can cause hypertension (high blood
pressure), even in infants and children. They have
been associated with seizures, heart arrhythmias, heart
attacks and death of bowel tissue due to blockage of
blood flow to the intestines. (5,6)
Also, cold medicines sold as syrups may contain up to
25% alcohol!
Remember, when these medications were compared to
placebo (basically sugar water), they had no greater
effect on children’s cold symptoms. If anything,
it seems odd that we have continued to fuel this
multi-million dollar industry by buying and using these
products on our children. Why has that happened?
Because as a parent, you want to make your child feel
better. You also want a reasonable night’s rest
for them and for yourself. I know that you don’t
want to give your child medicines with no likelihood of
benefit that can sometimes cause harm. What else
can you do?
First of all, remember that there is a reason for cough.
Your child coughs with a cold because cold viruses cause
irritation of his airways. They also cause
increased sinus secretions, which tend to pool in the
back of the throat. Your child needs to cough a
certain amount to move these secretions out of the upper
airway. Elevating the head of his bed at night
will allow some secretions to slide on down into the
stomach and may decrease his cough somewhat.
Increasing the amount of fluids that he drinks will help
keep those secretions thinner and more easily moved when
he does cough. Running a vaporizer at his bedside
may be soothing to those irritated airways, including
the nose.
It is also important to relieve nasal obstruction in
infants, who often will not feed well when they can’t
breathe through their noses. Use a bulb syringe
along with nasal saline drops before meals and before
naps or bedtime. (If you suction too often, you
may irritate the child’s nose and cause further
swelling.) For older children, nasal saline sprays
or drops will help to clean out their noses for easier
breathing.
If you’ve taken the above measures and your child is
still being woken up frequently by his cough, try a dose
of acetaminophen; maybe a sore throat is making the
cough more uncomfortable than it needs to be. Make
sure that the medicine you are giving is acetaminophen
alone, and not in combination with the above mentioned
cold medicines. If the cough still wakes your
child up frequently, see your pediatrician to make sure
that your child doesn’t have another infection on top of
his cold, and doesn’t have any evidence of asthma, which
may be present with no wheezing.
You should also see your pediatrician if your child’s
illness takes a sudden severe turn for the worse, if the
symptoms don’t improve fairly dramatically by around the
tenth day of illness, if your child isn’t drinking
enough to urinate six or seven times in every 24 hour
period, or if you are worried by any other symptom.
Meanwhile, take comfort in the fact that suppressing
your child’s cough is not necessary or helpful to
decrease his infectiousness. Cold viruses mostly
live in your child’s nose; very few are present in
saliva to be coughed out. However, viruses that
cause colds can survive on your child’s hands (and
yours) for up to two hours, and can survive on Kleenex,
door knobs, phones and other surfaces for up to two
days. To limit the spread of colds, wash
everyone’s hands often, and clean every surface that the
family touches with disinfectant wipes or sprays daily
until the sick ones are well.
References:
1. Magnani, Barbarajean and Richard Evans. Codeine
Intoxication in the Neonate. Pediatrics 1999;
104;775-77. Chest 2006; 129:260S-83S
2. Pender ES, Parks BR. Toxicity with
dextromethorphan-containing preparations: a literature
review and report of two additional cases. Pediatric
Emergency Care. 1991;7:163-165.
3. Food and Drug Administration.
Public Health Advisory Subject: Phenylpropanolamine.
Available online at:
www.fda.gov/cder/drug/infopage/ppa/advisory.htm
4. Lake CR, Gallant S, Masson E, Miller P. Adverse
drug effects attributed to phenylpropanolamine: a review
of 142 case reports. Am J Med. 1990;89:195-208.
5. Pentel P. Toxicity of over-the-counter
stimulants. JAMA. 1984;252:1898-1903.
 
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