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Overview of the risks and benefits of prescription and over-the-counter medications marketed for the treatment of the common cold in children

Overview of the risks and benefits of prescription and over-the-counter medications marketed for the treatment of the common cold in children
Active ingredient Mechanism[1,2] Potential benefits Potential risks*[1-3]

Antipyretics/analgesics:

Acetaminophen
Ibuprofen

   Reduction in temperature; little evidence regarding effects on discomfort[4] Acetaminophen may suppress the neutralizing antibody response, resulting in increased nasal secretions and prolonged viral shedding

First generation antihistamines:

Diphenhydramine
Hydroxyzine
Chlorpheniramine
Brompheniramine
Clemastine

 Anticholinergic effects decrease mucus secretionΔ No clinically significant benefits[5]
  • Sedation
  • Paradoxic excitability
  • Dizziness
  • Respiratory depression
  • Hallucinations
  • Tachycardia
  • Heart block
  • Arrhythmia
  • Dry mouth
  • Blurred vision
  • Urinary retention
  • Dystonic reactions

Narcotic antitussives¶◊:

Codeine
Hydrocodone

 Act on cough center in brainstem No more effective than placebo[5,6]
  • Respiratory depression
  • Nausea
  • Vomiting
  • Constipation
  • Dizziness
  • Palpitations

Nonnarcotic antitussives:

Dextromethorphan

 Act on cough center in brainstem No evidence of effectiveness[5-8]
  • CNS effects
  • Serotonin syndrome
  • Hallucinations
  • Respiratory depression (in overdose)

Oral decongestants:

Pseudoephedrine
Phenylephrine

 Vasoconstriction No evidence of effectiveness in children <12 years [9,10]
  • Tachycardia
  • Irritability
  • Agitation
  • Sleeplessness
  • Hypertension
  • Anorexia
  • Headache
  • Nausea
  • Vomiting
  • Palpitations
  • Dysrhythmias
  • Seizures
  • Dystonic reactions

Topical decongestants:

Oxymetazoline
Xylometazoline
Phenylephrine

 Vasoconstriction No evidence of effectiveness in children <12 years[10]
  • Rebound nasal congestion
  • Nosebleeds
  • Drying of nasal membranes
Antihistamine-decongestant combination

Anticholinergic effects (antihistamine)

Vasoconstriction (decongestant)

 No more effective than placebo[5,9,11] See potential risks for antihistamines and decongestants above

Expectorant:

Guaifenesin

 Increase mucus production to make secretions easier to remove with cough or mucociliary transport No studies of effectiveness in children[1,2,5]
  • Mild GI irritation

Mucolytics:

Acetylcysteine
Bromhexine
Letosteine

 Thin secretions to make them easier to clear through coughing Some evidence of improvement compared with placebo[5]
  • Bronchospasm
  • GI disturbance
  • Fever

Topical aromatics:

Menthol
Camphor
Eucalyptus oil

 May act on TRPM8 cation channel to produce a cooling sensation

Subjective improvement of nasal patency without objective increase in air flow[12]

Parental report of symptomatic improvement in nocturnal cough and sleep in poorly blinded study§[13]

 GI and CNS effects may result from accidental ingestion
Ipratropium bromide״ (nasal) Decreases nasal discharge via anticholinergic activity May decrease nasal discharge but not nasal congestion[14]
  • Nosebleeds
  • Nasal dryness
  • Headache
CNS: central nervous system; GI: gastrointestinal.
* Overdose is a potential risk with all of these agents, particularly when combination products are used.
¶ Because the risks outweigh the proven benefits, these medications generally are not recommended for children younger than six years of age. We suggest not using these medications in children 6 to 12 years of age.
Δ Histamine is not an inflammatory mediator in the common cold.
◊ Requires a prescription.
§ Significant placebo effect cannot be excluded.
¥ For children older than five years.
References:
  1. Pappas DE, Hendley JO. The common cold and decongestant therapy. Pediatr Rev 2011; 32:47.
  2. Kelly LF. Pediatric cough and cold preparations. Pediatr Rev 2004; 25:115.
  3. World Health Organization. Cough and cold remedies for the treatment of acute respiratory infections in young children, 2001. http://whqlibdoc.who.int/hq/2001/WHO_FCH_CAH_01.02.pdf (Accessed on August 30, 2011).
  4. Section on Clinical Pharmacology and Therapeutics, Committee on Drugs, Sullivan JE, Farrar HC. Fever and antipyretic use in children. Pediatrics 2011; 127:580.
  5. Smith SM, Schroeder K, Fahey T. Over-the-counter medications for acute cough in children and adults in ambulatory settings. Cochrane Database Syst Rev 2008; CD001831.
  6. Taylor JA, Novack AH, Almquist JR, Rogers JE. Efficacy of cough suppressants in children. J Pediatr 1993; 122:799.
  7. Paul IM, Beiler J, McMonagle A, et al. Effect of honey, dextromethorphan, and no treatment on nocturnal cough and sleep quality for coughing children and their parents. Arch Pediatr Adolesc Med 2007; 161:1140.
  8. Paul IM, Yoder KE, Crowell KR, et al. Effect of dextromethorphan, diphenhydramine, and placebo on nocturnal cough and sleep quality for coughing children and their parents. Pediatrics 2004; 114:e85.
  9. Clemens CJ, Taylor JA, Almquist JR, et al. Is an antihistamine-decongestant combination effective in temporarily relieving symptoms of the common cold in preschool children? J Pediatr 1997; 130:463.
  10. Taverner D, Latte J. Nasal decongestants for the common cold. Cochrane Database Syst Rev 2007; CD001953.
  11. Hutton N, Wilson MH, Mellits ED, et al. Effectiveness of an antihistamine-decongestant combination for young children with the common cold: a randomized, controlled clinical trial. J Pediatr 1991; 118:125.
  12. Kenia P, Houghton T, Beardsmore C. Does inhaling menthol affect nasal patency or cough? Pediatr Pulmonol 2008; 43:532.
  13. Paul IM, Beiler JS, King TS, et al. Vapor rub, petrolatum, and no treatment for children with nocturnal cough and cold symptoms. Pediatrics 2010; 126:1092.
  14. Albalawi ZH, Othman SS, Alfaleh K. Intranasal ipratropium bromide for the common cold. Cochrane Database Syst Rev 2011; CD008231.
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