That Annoying Cough....Why Cough Medicine is Not Recommended

It's 3:00am and you are suddenly awoken by the sound of your child coughing in your ear. You've tried the humidifier, the steaming shower, yet nothing seems to be working.  A few hours later you decide to send your spouse out to get something....but what?  The internet is full of advertisements and a whole variety of medicines that promise to make your child better.  Your spouse gets to the pharmacy just as they are opening.  Upon perusing the many options, he/she decides to ask the pharmacist.  The Pharmacist picks out a few options, your spouse arrives home, and you start the medicine immediately.  Hours later, after realizing it isn't helping, your child asks you to help her feel better. What is a parent to do???

It's that time of  year again.  For the past few months, "The Cough" has hit Fredericksburg with a vengeance. Unfortunately, despite the wide variety of cough medicines available to parents these days, the evidence is not there to support their use in children. Since 1985, all six appropriately done studies have shown that in children under 12, there is no meaningful differences between the active drug and placebo(a syrup or pill with no medicine).   Despite the lack of evidence, they are still heavily marketed to children and their families.  What parents don't realize is that, although they don't have much effect, they can cause harm. From 2000-2007, 75,000 calls were made to poison control centers nationwide.  Among the concerns are findings, in children under 6, there have been cases of decongestants (example: Dimetapp) causing cardiac arrythmias and other cardiovascular events, antihistamines (example: Triaminic) causing hallucinations, and antitussives (ex: Delsym, Robitussin)  causing depressed levels of consciousness.  A recent FDA review showed 123 deaths related to these products in children under 6.

For those of you out there who are like me, you want to know what the evidence based literature does show. Below, I have outlined the different classes of medicines and what information we do have now. This is not exhaustive, but hopefully it is helpful.  For those of you who just want the summary, it is at the bottom.

Antihistamines (Triprolidine, dephenhydramine, hyroxyzine, chlorpheniramine, brompheniramine maleate)

These medicines (Benadryl, Atarax, etc) are what some parents look to first. They are also in a lot of the combination products available over the market.  In one study of antihistamine-decongestant combination, there was no improvement over placebo(no medicine). However, those treated were more likely to be asleep 2 hours after receiving medication. Another study showed no decrease in nasal discharge, although the color of the discharge changed from yellow to white.  Finally, one study did demonstrate that  diphenhydramine at bedtime was no better than placebo in reducing cough or improving sleep.

Decongestants (pseudoepedrine, phenylpropanolamine, phenylephrine)

These medicines (like Sudaphed) are usually added to other preparations and will add the letter -D to the name (ie: Mucinex-D).  For adults, there is evidence that shows these medicines can reduce nasal symptoms(congestion/sneezing).  So even though this medicine may be helpful to you,  there is currently no evidence that supports the effectiveness in children.  One study showed no improvement in nasal congestion, runny nose, or cough. More importantly, because infants are nose breathers - these medicines can be dangerous to infants and in fact have caused death in this age group.

Antitussives( dexromethorphan )

This medicine, under the brand name Delsym and Robitussin, is the non-narcotic version of codeine.  One study of children 18 months 12 years of age showed no difference in cough between placebo, dextromethorphan, or codeine related groups.  The good news was that the cough decreased in all three groups in exactly the same time.  Another study in children ages 2-18 years old found  that even going up on the dose did not leave to improvement in cough.

Accidental overdose of these medicines can cause respiratory depression and there are reports of death in children under 5 year of age. Because of the lack of efficacy and the risk of serious side effects, the American Academy of Pediatrics(AAP) does not recommend the use of dextromethorphan in children.

Codeine

Codeine is the medicine we all grew up getting. It seemed to make us sleepy and our parents and grandparents swear it was the best thing their pediatrician ever did.  Although codeine used to be considered the "gold-standard" cough medicine,  no studies in adults or children support its use for treatment of cough.
One study of patients 18months-12 years showed codeine as no more effective than placebo for cough suppression in children who had nighttime cough. As with dextromethorphan, the American Academy of Pediatrics(AAP) recommends against its use in children.

Expectorants (Guaifenesin aka Mucinex)

 This jury is still out here.  There have been some studies that show some subjective improvement in mucous thickness in young adults and adults with no change in cough. However, studies in children demonstrating effectiveness do not exist.

Honey

Surprisingly, this home remedy may have some use. A recent study suggests that honey may provide some relief from nighttime cough in children.  In this study, a bedtime dose of honey was better than no treatment in alleviating cough symptoms.  Honey should NOT be given to any children UNDER 12 MONTHS of age.

WARNING: COUGH MEDICINE AND YOUR ASTHMATIC(or Reactive Airway Disease)

Your child's asthma medication is the best medication for cough and wheeze. Although your child may not be wheezing, it is recommended that a child with asthma use their inhaler at least twice a day during a coughing episode to prevent further progression of that illness.  If you are using your child's inhaler/nebulizer and the cough is not improving, please come in to be seen.  

It is NOT recommended that you use ANY cough medicine when you have asthma.  The cough is your body's mechanism to help keep the airway open and we do not want to suppress this mechanism in any child with asthma.  Even though the evidence, as above, shows limited suppression of cough, these medicines are not recommended.

In Conclusion...

  What do you do with those medicines you just purchased? The best answer is to probably throw them away.   I understand, as a parent, we just want to do something to help our children feel better.  It is hard to see your child coughing and feel so hopeless. Unfortunately,  the evidence is just not there for using cough medicines for you child.  If you plan to try anything, the best first step is Honey(in your > 12 month old).  Although it is not the perfect cure, it is safe, natural, and may be effective.

So....when should you worry or have your child seen?

1) Your child is an asthmatic or has reactive airway disease and is not responding to their albuterol/xopenex medications.
2) Your child has a progressively worsening cough and/or has a persistent fever.
3) Your child is having a hard time breathing (go to the ER or call 911)
4) Your child's cough is lasting longer than 2 weeks.
5) Your child is having a barky cough.
6) Your child is having coughing fits(or spasms) that are keeping him/her from breathing.
7) You have a small infant or newborn that is coughing
8) You child has any other symptoms that are causing you to worry.
9) This list is not exhaustive, please call your child's pediatrician if you have questions or concerns!


Note:  All comments are welcome on the blog, but please do not post medical questions. I am, unfortunately, unable to respond to personal medical questions through this website.   Thank you for understanding!

Dr. M

Legal Disclaimer: This blog is designed to provide general information related to pediatric and adolescent care. The information presented on this blog should not be construed as formal medical advice, nor does accessing this site constitute formation of a doctor (or other healthcare provider)-patient relationship. The content is intended solely for informational and not for treatment purposes. Do not use this site if you believe you may have a medical emergency; call 911 or your doctor's office immediately.