Pediatric Corner for February 2013
“Why Pediatricians say no to cold medication.”
The most common question I get at this time of year is “What can I give to my child for his/her
runny nose and cough. The American Academy of Pediatrics (AAP) has made this answer easy by not
recommending any over the counter cough/cold medication to children under 6 years of age. The
parents follow up question is the hard one: WHY?
First parents need to realize that cold medication does not treat the virus. It is designed to
lessons the body’s reaction to the virus. The cold is going to run its course in 5-10 days with or without
the medication. As pediatricians, we recommend therapies that are both safe AND effective.
Unfortunately, we are unable to say that cold medications are either safe or effective because there are
no well designed studies with children for these medications.
I am always reminding parents that children are not “little adults”. Children can have side
effects that were not seen in the adult studies. Unfortunately, the way we are finding out that these
cold medications are not safe is through the emergency room. In the past, the average number of ER
visits for children due to cold medications was over 2,700 per year. Most of the ER visits are due to
overdose because the parents gave two different cold medications to their child that had the same
medication in them. Then in 2007, the FDA recommended that no cold medications be approved for
children less than 2 years of age because of all the adverse events. Since, the average amount of ER
visits has dropped over 50% to around 1,200 visits/year.
Let me go over the way that each medication works and side effects associated with that
medication. The most common medication for runny nose and congestion are decongestants such as
pseudoephedrine or phenylephrine. These medications are known to decrease swelling in the nasal
passages and relieve the congestion in adults. However, the few studies done on children did not show
the same benefits. Also, most of the side effects of these medications are related to the heart and
brain. Infants cannot tell us that their heart is not beating normally. The cardiac effects, including
increased blood pressure and increased heart rate can lead to arrhythmias. The neurologic effect of
increased excitability can lead to seizures. Both of these events have caused deaths in children.
The next class of medication is cough suppressants. The most common medication you will see
on the label is dextromethorphan HBr. The body coughs for a reason. It is a protective reflex triggered
in the brain to avoid swallowing fluid in the lungs. These medications work by altering brain activity to
suppress this protective reflex. If the cough is wet because of mucous, not clearing the mucous can lead
to more serious infections like pneumonia. Serious side effects include a decreased drive to breathe
(respiratory depression), seizures, and rapid heart rate.
Another common class of medications is antihistamines such as Benadryl. Histamine is released
in response to allergies. In studies, viruses are not shown to induce much histamine release and these
medications have no known benefits to treat colds in children. However, we do know of many side
effects of these medications in children. In a certain percentage of children, they can cause excitability
(increased heart rate). Parents say their children are “bouncing off the walls” after taking it. However,
the serious side effect of antihistamines is respiratory depression.
As you can see, many of the major side effects of these three types of medications are the same.
This is why it is dangerous to give multi-symptom cold medication. In most cases of the deaths related
to cold medications, a combination of nasal decongestants, cough suppressants, and antihistamines are
found in their system.
Safer medications for children OVER six years of age are expectorants such as guaifenesin
(Mucinex). The way they work is by bringing water to the airway and thinning mucous. This is similar to
saline drops. This class of medication has no serious side effects in infants or children that we are aware
of. However, no large studies have been done in children. Therefore, they are not endorsed by the FDA
or AAP to use in children under 6 years of age.
Vapor rubs fall into a similar category of medication with an unknown safety profile in children
because of limited studies. There was one well done study in 2010 on children over the age of 2
showing improvement in symptoms and sleep with vapor rubs. No major side effects were reported in
that study. In 2011, an article in the AAP newsletter included vapor rub as a safe treatment option for
colds in children OVER 2 years of age.
In my office, what I recommend to parents to help make their child more comfortable during a
cold is a cool mist humidifier for the room, saline nose sprays, and bulb suction (for babies). Parents can
give ½ teaspoon (younger children) up to 1 tablespoon (adolescents) of honey if your child is OVER one
year of age to soothe the throat and help their cough. (We worry about botulism in children less than
one year of age.) After two years of age, one could place vapor rub on their chest.
Hopefully this gives you some insight of the dangers of over the counter cold medication for
children and why I do not recommend these products for children.