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Tuesday, October 1, 2013

Cough Medicine: Which one's best?

This is the time of year I get a lot of requests for an over the counter cough suppressant suggestion or a prescription cough medicine for kids so they can sleep. Despite my attempts at educating the family about why I don't recommend any cough medicines, many parents are upset leaving without a medicine. I have collected numerous articles that show why I treat cough the way I do. Links are included throughout this blog. Click away to learn more!

First, a little background...


Most cough medicines were studied in adults and the dosing for kids was calculated from the adult dosage. Kids are not small adults. Their bodies handle illness and metabolize drugs differently. But few studies have been done to show if medicines work at all, and if they do, what the best dose is for kids of various ages and sizes.

In 2008 the FDA stated that toddlers and babies should not use cold and cough medicines. Drug makers voluntarily changed the labeling of over the counter (OTC) cough and cold products, recommending them only for children aged 4 and older. The American Academy of Pediatrics says there is no reason that parents should use them in children under age 6 because of the risks without benefit. Despite this, studies show that 60% of parents of children under 2 years have given a cough and cold medicine. Why? In my opinion, they are desperate to help their child and don't think it is enough risk to not at least try.


cough, cold, medicine, sick, child



I know it is frustrating when your child is up all night coughing. It is frustrating when my kids and I are up all night coughing. But you know what we do in my house?

  • Humidify the air of the bedroom (unless it's a spring or summer cough)
  • Extra water to drink all day
  • Honey before bedtime in an herbal tea (No honey before 1 year of age!)
  • Encourage cough during the day to help clear the airways
  • Nasal rinse with saline (I love this, but my family is not so keen on it)
  • Sleep with water next to the bed to sip on all night long (even when I still had bedwetters)
  • Back rubs, hugs, kisses, reminders that it will get better, etc
  • Nap during the day as needed to catch up on lost sleep
  • Watch for signs of wheezing or distress

That's about it for the cough. If something hurts, we use a pain reliever like ibuprofen or acetaminophen. We use those only if something hurts, not just because and not for fever without discomfort.

Why don't I give my family cough medicines?

Because they don't work.

The OTC options:


A Cochrane Review in 2007 was done to look at over the counter cough medicine effectiveness in both children and adults. These reviews look at many studies and analyze the data. Unfortunately there are very few studies, and many were of poor quality because they relied on patient report. In studies that included children, they found:

  • Antitussives were no more effective than placebo for kids. (one study) In adults codeine was no more effective than placebo. Two studies showed a benefit to dextromethorphan, but another study did not, so mixed results.
  • Expectorants had NO studies done in children. In adults guaifenesin compared to placebo did not show a statistically different response. 
  • Mucolytics more effective than placebo from day 4-10 in kids. (one study) In adults cough frequency was decreased on days 4 and 8 of the cough. (Note: I am not sure what OTC mucolytic was studied. I am only aware of pulmozyme and mucomyst, both used by prescription in children with cystic fibrosis.)
  • Antihistamine-decongestant combinations offered no benefit over placebo. (2 studies) One of two studies showed benefit in adults. The other did not.
  • Antihistamine shows no benefit over placebo. (one study) In adults antihistamines did not help either.

Another Cochrane Review in 2012 once again failed to show any real benefits of cough medicines, especially given the risks of side effects.

What about some specific studies on OTC medicines? I cannot report them all here, but here's a few:


A study comparing dextromethorphan (the DM in many cough medicines), diphenhydramine (AKA benadryl), and placebo in 2004 showed no difference in effectiveness of controlling cough for sleep. That means the placebo worked just as well as the medicines. Insomnia was more common in those who got dextromethorphan.

Does guaifenesin help? It is thought to thin mucus to help clear the airways. It does not stop the cough. Studies vary in effectiveness and are typically done in adults, but it may be helpful in children over 4 years of age. Do not use combination cough medicines though, for all the reasons above.

In 2007 honey was shown to be a more effective treatment than dextromethorphan or no treatment. Another study in 2012 showed benefit with 2 tsp of honey 30 minutes before bedtime. A side effect of honey? Cavities... Be sure to brush teeth after the honey!

What side effects and other problems are there from over the counter cough medicines?

As stated above, the dosages for children were extrapolated from studies in adults. Children metabolize differently, so the appropriate dosage is not known for children. Taking too much cold medicine can produce dangerous side effects, including shallow breathing and death.

Many cough medicines have more than one active ingredient. This can increase the risk of overdosing. It also contributes to excess medicines given for problems that are not present. For instance if there is a pain reliever plus cough suppressant, your child gets both medicines even if he only has pain or a cough. Always choose medicines with one active ingredient.

Accidentally giving a child a too much medicine can be easy to do. Parents might use two different brands of medicine at the same time, not realizing they contain the same ingredients. Or they can measure incorrectly with a spoon or due to a darkened room. Or one parent forgets to say when the medicine was given and the other parent gives another dose too soon. 

And then there's non-accidental overdose. There is significant abuse potential: One in 20 teens has used over the counter cough medicines to get high. Another great reason to keep them out of the house!

Side effects of cough medicines include:
  • Nausea and vomiting
  • Stomach pain
  • Confusion
  • Dizziness
  • Double or blurred vision
  • Slurred speech
  • Shallow breathing
  • Impaired physical coordination
  • Rapid heart beat
  • Drowsiness
  • Numbness of fingers and toes
  • Disorientation
  • Death, especially in children under 2 years of age and those with too high of a dose



What about prescription cough suppressants? 


In 1993 a study comparing dextromethorphan or codeine to placebo showed that neither was better than the placebo. Codeine belongs to a class of medications called opiate analgesics and to a class of medications called antitussives. When codeine is used to reduce coughing, it works by decreasing the activity in the part of the brain that causes coughing. It can make breathing too shallow in children. Codeine has several serious side effects which could be life threatening in children. Combination products with codeine and promethazine (AKA phenergan with codeine) should never be used in children under 16 years. In my opinion, why use it in older children and adults, since it hasn't been shown to work?

How about antibiotics for the cough?

Antibiotics may be used to treat bacterial causes of cough (such as some pneumonia or sinusitis illnesses) but antibiotics have no effect on viruses, which cause most coughs. If your child has a cold, antibiotics won't help.