Dr Rashmi Sharma
Parents usually bring children to doctor’s clinic with acute respiratory tract infection (ARTI) with history of cough, fever, sour throat, blocked nose, difficulty in feeing etc. In both developed and developing countries the incidence of ARTI per child per year is 6-8.Cough and cold syrups are one of the most commonly used / sold medicines in India. These syrups (containing the decongestants- ephedrine, pseudoephedrine, or phenylephrine, and the antihistamines- diphenhydramine, brompheniramine, chlorpheniramine) are available both as prescribed drugs (by prescription of doctors) and over the counter drugs (without doctor’s prescription). Drops/ syrups like sinarest, cinaryl, triminic etc. are frequently brought by parents with or without doctor’s advise for their infants (less than one year) and children .
Cough and cold products contain ingredients like: decongestants (for unclogging a stuffy nose), expectorants (for loosening mucus so that it can be coughed up), antihistamines (for sneezing and runny nose), and antitussives (for quieting coughs). Histamine is similar in structure to biological amines like acetylcholine,adrenaline, serotonin, etc and hence, antihistaminic interfere with these biologic amine receptors and interfere with their actions. Sedative effect and paradoxical excitement caused by their use along with poor clinical evidence of them as effective antitussives agent in children make them unfavourable as antitussive agent in children. Most of the decongestants (both nasal drops and oral syrups) contain sympathomimetic drugs. These drugs produce stimulation of heart and central nervous system, constriction of blood vessels and dilatation of bronchi. Topical decongestants if used for 2-3 days can result into rebound dilatation of blood vessels in nasal mucosa leading to stuffiness which is problematic in young children and infants who are nose breathers. Moreover, dose of topical agents could not be monitored which is often associated with systemic absorption of drug and its relativeside effects(sedation or excitement of central nervous system, convulsions, tachycardia etc.). Psychic disturbances reported among children following oral phenylpropanolamine administration include irritability, sleep disturbances, hallucinations, aggressiveness (particularly in younger children), and seizures. Severe hypertensive episodes have been reported following phenylpropanolamine ingestion. Pseudoephedrine is relatively safe than other sympathomimetic agents. In a study of 81 965 prescriptions of pseudoephedrine to children under the age of 19,only one hospitalization (for a seizure) which could have been related to use ofPseudoephedrine. Antihistamines are the mainstay of therapy for allergic rhinitis and the resemblance between cold symptoms and symptoms of allergic rhinitis led to the use of antihistamines for the common cold. However, histamine is not present in increased concentrations in persons with upper respiratory infections. Hence, there is no rationale for their use in the common cold. Promethazine, an antihistamine widely used for its anti-emetic and sedative properties, has been reported to cause agitation, hallucinations, seizures, dystonic reactions, sudden infant death syndrome, and apnoea. However, the efficacy of promethazine as a sedative could lead to its misuse by parents who may have to cope with a screaming child. Second-generation antihistamines have fewer anticholinergic and sedative effects ,but with poor efficacy.
However, in 2008 US Food and Drug Administration (FDA) has advised against the use of over-the-counter cough and cold medicines in children less than two years of age. FDA also advised to use these medicines in children aged 2-11 years with caution. FDA advised to have extreme caution in children of any age with history of neurological disorders, seizures, hypotonia, heart disease, and in view of the risk of respiratory depression, it is advised that a child under two years of age should not be given any kind of cough and cold product containing decongestants or antihistamines, without seeking the advice of a healthcare provider. In January 2008, manufacturers voluntarily removed over-the-counter (OTC) infant (less than 2 years of age) cough and cold products from the market due to safety concerns. But, even now cough and cold products designed for older children are frequently prescribed by doctors and used by parents for children less than 2 years. These medicines were used in younger children by making self-styled dose adjustments like half of the dose of older child. However, there are reports regarding serious side-effects and even deaths in children under 2 years due to accidental ingestion, unintentional overdose, or after a medication dosing error. However, various simple ways can be used to make parents stress free by giving relief to their little ones. These recommendations are:
” A cool mist humidifier helps nasal passages shrink and allow easier breathing (warm mist humidifiers can cause nasal passages to swell and make breathing more difficult); *Saline nose drops or spray keep nasal passages moist and helps avoid stuffiness;* Nasal suctioning with a bulb syringe either with or without saline nose drops, works especially well for infants less than a year old ;* Acetaminophen (paracetamol) or ibuprofen can be used to reduce fever, aches and pains;*Drinking plenty of liquids will help the child stay well hydrated.
“It is further advisable to follow the dosing directions on the label of any OTC medication for children above 2 years, understand that these drugs will NOT cure or shorten the duration of the common cold, check the “Drug Facts” label to learn what active ingredients are in the products because many OTC cough and cold products contain multiple active ingredients, and only use measuring spoons or cups that come with the medicine or those made specially for measuring drugs. If one is using more than one OTC cough and cold medicine to a child always check whether they have same or similar “active ingredients,”(danger of over dose). OTC cough and cold medicines with childproof safety caps should be stored out of reach of children to avoid accidental overdosing.
(The writer is pharmacologist working as Asist. Surgeon Emergency Hospital Vijay Pur, Jammu)
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