The short answer is...no
There is little evidence that cough and cold preparations containing antitussives, mucolytics, expectorants, decongestants
or antihistamines, have any clinically significant effect on reducing the symptoms or duration of the common cold in children.
In addition, Medsafe recommends that cough and cold preparations containing certain medicines (Box 1) should not be
used in children aged under six years.1 This decision was made based on the balance of benefit, which is low,
versus risk – there is a significant potential for adverse effects and risk of toxicity in overdose.
Box 1. Cough and cold preparations containing the following medicines should not be used in children
aged under six years:1
- The antihistamines brompheniramine, chlorpheniramine, diphenhydramine, doxylamine, promethazine or triprolidine
- The antitussives (cough suppressants) dextromethorphan or pholcodine
- The expectorants guaifenesin or ipecacuanha
- The decongestants phenylephrine or pseudoephedrine
Cough and cold preparations are now required to be labelled as such, although some companies may still be phasing in
new product packaging.
A list of cough and cold preparations available in New Zealand that are affected by these restrictions
is available from:
www.medsafe.govt.nz/hot/alerts/coughandcold/affectedmedicinesoct2009.asp
N.B. Medsafe advises that preparations containing only bromhexine (mucolytic) or intranasal decongestants such as oxymetazoline
and xylometazoline remain restricted to use in children aged over two years.1
Cough and cold preparations
Cough and cold preparations are designed to provide relief from the symptoms of viral respiratory infections.
Cough and cold preparations commonly contain:
- Mucolytics/expectorants which aim to loosen phlegm from the respiratory tract, making it easier to expel e.g. bromhexine,
guaifenisin
- Antitussives which aim to decrease the urge to cough e.g. pholcodine, dextromethorphan
- Nasal decongestants which aim to reduce the amount of fluid reaching the nose and reduce swelling inside the nose
e.g. phenylephrine, pseudoephedrine
- Antihistamines which are used based on the premise that they reduce similar types of symptoms in allergies (rhinitis,
sneezing) e.g. promethazine, diphenhydramine
Sales restrictions on cough and cold preparations for children aged under 12 years
Medsafe has recently announced that cough and cold preparations containing dextromethorphan, phenylephrine and ipecacuanha
will now be required to be re-labelled for use in adults and children aged over 12 years, when sold in supermarkets.
These products will still be available for sale to children aged between six and 12 years at pharmacies, where parents
can receive professional advice on their use and safety.2
This restriction does not apply to cough and cold preparations containing ingredients such as glycerol, honey, lemon
and other natural substances. These products will remain for general sale in supermarkets.2
Limited evidence of effectiveness in children
Although widely used, cough and cold preparations containing any of these medicines, or combinations, are not particularly
effective at reducing symptoms in children. Infection with the common cold affects children and adults differently, therefore
products which may be effective for adults do not necessarily work in the same way for children. It is acknowledged that
the placebo effect may play a significant role in the anecdotal success and popularity of using cough and cold preparations.
A recent review of over-the-counter cough preparations in children found that antitussives, antihistamines, antihistamine/decongestant
combinations and antitussive/bronchodilator combinations were no more effective than placebo in alleviating symptoms of
cough and cold. There was insufficient evidence to evaluate expectorants or mucolytics.3
There is no evidence to support the use of beta-2 agonists e.g. salbutamol in children with acute cough with no airflow
obstruction. They do not reduce the incidence or severity of cough.4
Harmful effects
Most cough and cold preparations contain either a CNS depressant (e.g. promethazine) leading to possible sedation, psychomotor
impairment, dizziness and hallucinations or a CNS stimulant (e.g. phenylephrine) leading to possible insomnia, tremor,
hallucinations and palpitations. Combination products increase the risk of CNS effects, resulting in additive drowsiness
or paradoxical CNS stimulation. It is recommended that the use of CNS-acting medicines in children is avoided unless there
is a clear need and benefit.
There is some suggestion that cough suppressants may cause retention of sputum. This can be harmful as the retained
sputum then becomes a site for bacterial infection e.g. as in bronchiectasis.5
Other treatments for cough and cold
As parents begin to accept that cough and cold medicines may not be appropriate or effective for their child, other
treatments are likely to be sought.
Consider paracetamol or ibuprofen
Paracetamol can be considered first-line for the treatment of pain and fever associated with cough
and cold. Ibuprofen may also be significantly effective for associated headache, earache, muscle and
joint pain, and could be considered for children as a second-line alternative to paracetamol.6
Saline
Saline drops or spray may be used as a nasal decongestant, particularly in younger children and infants. Commercial
products are available (sodium chloride 0.9%). Alternatively a home-made salt water solution could be used: mix ¼ tsp
salt with two cups of cooled, boiled water and administer using a small spray bottle, nasal dropper or syringe.
Honey
Honey is often suggested as a suitable treatment for cough and cold, largely due to its demulcent properties, which
act to soothe the throat and mucous membranes. Honey* can be administered
directly on a teaspoon or given as a warm honey and lemon drink. Lozenges are not recommended due to the risk of choking.
Honey is not recommended in children aged under one year due to its rare association with infant botulism.7
A systematic review of the clinical effectiveness of honey for cough and cold symptoms, found that there was insufficient
evidence to advise for or against its use.8 Honey was more effective in reducing frequency of cough and bothersome
cough and improving sleep quality of the child, compared to no treatment. However, there was no difference between honey
and no treatment, in reducing the severity of cough or the sleep quality of parents.8
Despite the lack of clinical evidence, honey can still be regarded as a safe treatment to trial for a child, aged over
one year with cough and cold.
Aromatic inhalations and decongestants
Aromatic compounds such as menthol and eucalyptus oils can be added to warm water to create a vapour, which is inhaled
to relieve congestion and ease breathing. This encourages inspiration of warm, moist air which can also provide comfort.5
A systematic review of steam inhalation used for the common cold in adults concluded that there was insufficient evidence
to determine whether there was any beneficial clinical effect. For some people, the steam inhalation worsened the symptoms
of congestion.9
If this treatment is to be trialled for a child, it is important not to use boiling water due to the risk of scalding.
In addition, accidental ingestion of aromatic oils, even in small amounts, is associated with a significant risk of CNS
depression (due to toxicity) and aspiration (due to volatility). Remind parents that aromatic oils and inhalation solutions
should be stored out of reach of children.
Aromatic decongestant rubs (e.g. Vicks VapoRub) are also used to provide comfort. They may be applied directly onto
the throat, chest or back or onto a pillow or clothing for children with sensitive skin. Aromatic rubs are not recommended
for use in children aged less than three months.5 Care must be taken to avoid ingestion due to the toxic nature
of these products. There is no evidence that aromatic rubs have any clinically significant effect on cough and cold symptoms.
Ivy leaf extract
“Bronchial syrups” containing ivy leaf extract (Hedera helix) are commonly used throughout Europe for the
treatment of cough and cold, and are gaining popularity in New Zealand. As this product is classified as a dietary supplement,
there are no associated age restrictions for its use.
There is currently little evidence of clinical effectiveness of ivy leaf extract for treatment of cough and cold. A
review of randomised controlled trials, testing the efficacy of ivy leaf extract in children with bronchial asthma, concluded
that ivy leaf preparations have some effect on improving respiratory function, but there is insufficient evidence to make
any recommendations for their use.10
Alternative remedies for cold prophylaxis and treatment
There is little evidence of effectiveness of products such as vitamin C, echinacea and garlic, which are commonly used
for prevention and treatment of cough and cold (Table 1). These products are not recommended in children based on their
lack of proven benefit.
| Table 1: Evidence of effectiveness of non-pharmacological treatments for cough and cold |
| Intervention |
Study population |
Conclusions |
| Echinacea |
Adults and children receiving echinacea for prevention or treatment of the common
cold, compared to placebo and other treatments |
There is no evidence that echinacea prevents occurrences of cold.
There was mixed evidence of echinacea as a treatment for cold, however overall no beneficial effect was shown.
Echinacea medicines differ greatly (by species, parts of the plant used and manufacturing methods). There
is some evidence that medicines based on the aerial parts of E. purpurea might be more effective than other medicines
in adults.11 |
| Garlic |
Adults receiving either garlic supplement (180 mg allicin) or placebo daily for 12
weeks |
A single trial suggested that garlic may prevent occurrences of cold, but does not
reduce duration. More studies are needed to validate this finding.12 |
| Vitamin C |
Adults and children receiving ≥ 0.2 g vitamin C per day as prophylaxis or therapy
after symptom onset for the common cold |
There was some evidence that prophylactic vitamin C modestly reduced the duration
and severity of cold symptoms. This effect was slightly greater in children (duration of cold reduced by 13% compared
with 8% in adults).
There was no evidence that therapeutic vitamin C reduced the duration of cold or alleviated symptoms.
Routine prophylaxis or therapeutic use of vitamin C is not justified.13 |
Advice for parents
So if cough and cold preparations are not suitable for children and most alternative remedies lack evidence of effectiveness,
what can parents actually do?
- Simple analgesia, such as paracetamol or ibuprofen, may be given as required for general aches and pains, fever and
headache associated with cough and cold.
- For nasal congestion, a saline spray or drops can be effective and is well tolerated, without adverse effects. This
is especially helpful in young children and infants.
- Honey (straight or added to a drink) may be trialled in children aged over one year, for the purpose of providing
comfort.
- Provide general care such as encouraging rest, ensuring adequate fluid intake and keeping warm.
Cough and cold preparations are not recommended, but if they are used in children aged over six years, advise parents
to follow dose instructions carefully. Do not give more than one type of medicine at a time and do not use for longer
than five days.
Focus on environmental factors
One of the most important things that parents can do for their child with cough and cold, is to provide a “healthy
home” environment.
Encourage parents to make their home smoke free. Children exposed to cigarette smoke are more likely to develop asthma,
chest infections e.g. bronchiolitis, ear infections and many other health problems.14
Make sure the house is warm and dry. Heat pumps, wood pellet burners and flued gas appliances are preferable to multi-fuel
or coal burners, electric heaters and unflued gas heaters, which are associated with the release of moisture, nitrogen
dioxide and emissions into the internal environment. The New Zealand Healthy Homes study demonstrated that there was a
significant improvement in the self-reported respiratory health of families who received retro-fitting of insulation in
their homes.15
A “healthy home” environment also means that children are provided with warm clothing and good nutrition.
Good hygiene practices e.g. hand washing, covering the mouth and nose with a tissue when coughing or sneezing, should
also be encouraged to help prevent transmission of cough and cold to others in the household.
The Energy Efficiency and Conservation Authority (EECA) provides funding to
assist people in insulating their homes and installing clean and efficient heating. Homeowners with houses built before
2000 are eligible. People in rental homes should speak to their landlords.
Local providers can be located on the EECA website: www.energywise.govt.nz
Acknowledgement
Thank you to Associate Professor David Reith, Paediatrician and Clinical Pharmacologist, Paediatrics
and Child Health, Dunedin School of Medicine, University of Otago for expert guidance in developing this article.