Coughing from a cold or the flu is probably the most frustrating symptom we can have -- for children, their parents and even the doctor treating them. Why? Because there's honestly very little we can do to treat a cough.
That's a hard pill to swallow, and it's especially humbling for me as a family physician. It's also very frustrating for me as a father of two toddlers who just started day care and are fighting new viruses every week. As my wife and I comfort them at 2 in the morning, I face the same question from her as from parents in my clinic: Which cough syrup should we use?
The good and bad of coughing
First, it's important to note that a cough is generally a good thing. It's our body's natural attempt to get rid of germs and toxins, so it's not a healthy idea to suppress a cough too much.
Of course, a cough can become too severe or painful, and lack of sleep isn't good for anyone's immune system. So overall, I think it's reasonable to try something safe. But no matter what you use, nothing makes a cough go away for more than a couple of hours.
Concerns about overdosing in children
Having said that, I'd like to help you cut through confusion at your pharmacy and make this simple: Don't bother with almost any of the over-the-counter, or OTC, cough syrups. First, try some honey.
Pharmacy shelves have a bewildering assortment of cough and cold medicines. It's confusing for me as well, even with my training! Overdosing is quite a problem, especially for children.
In fact, in 2008 drugmakers voluntarily (with a gentle push from the Food and Drug Administration) withdrew some medicine and changed warning labels. They pulled from store shelves all cough medicines used for children under 2, and changed warning labels to say: "Do not use in children under 4 years of age." (You can read the FDA statement here).
Strict guidelines from pediatricians
The American Academy of Pediatrics is even stricter: no OTC cough medicines for children under 6, and caution for ages 6 to 12. The major concern has been the number of overdoses, even deaths, in children taking too much of these medicines. Especially dangerous is acetaminophen, commonly known as Tylenol, which is added to cough medicines for pain and fever relief. A proper dose works wonderfully, but in high doses it can cause liver failure.
Not only are OTC medicines potentially dangerous, but they barely work. For example, the decongestant phenylephrine, which is in almost every combination cough-and-cold medicine, is no better than a placebo in the best research results. In other words, there's a good reason your runny nose isn't getting better -- it's because the medicine you’re taking doesn't work.
Some OTC drugs actually behind the counter
A couple of years ago, phenylephrine replaced the far more-effective drug pseudoephedrine in many combination medicines after people began buying pseudoephedrine-containing pills in bulk and cooking them down to make methamphetamine. So now, if you really want sinus relief, you have to ask the pharmacist for pseudoephedrine. It's still available without a prescription, but it’s actually behind the counter and you're only allowed two boxes.
The bright side to all of this is that the most useful cough syrup may be in your home right now. It’s honey! A Cochrane database review from 2014 showed that honey helped more than dextromethorphan and diphenhydramine, both common ingredients in cough syrup, for cough frequency, severity and quality of sleep. This applies to children and adults.
Here’s my advice for treating coughs by age:
1 year and younger: No OTC syrups are safe. This includes honey-based remedies because they carry the risk of botulism. The best advice is to care for the cause of the cough, often post-nasal drip, by using nasal saline drops or spray. A bedroom humidifier can also help if the room is too dry, especially on cold winter nights.
Coughing can cause a sore throat or rib inflammation, and that can cause pain. If your baby is fussy but has no fever, he or she may be in pain. Don't be afraid to give your child ibuprofen or acetaminophen syrups for comfort and better sleep.
Probiotics also can help. A growing number of studies have shown they are effective in reducing the length of a cold, severity of symptoms and time away from school or work. The best research is on bifidobacteria and lactobacillus GG probiotics.
Also, don't forget an annual flu shot for any child over 6 months of age. If they're younger than 6 months, they're vulnerable to the flu, so it’s important for all of your baby’s caretakers and family members to get a flu shot as well. This will help ensure they don’t become ill and pass the flu on to the baby.
1-6: I think honey or honey-based herbal mixtures (not homeopathic remedies) should be the first choice for a cough, along with probiotics. Taking care of nasal congestion often can help ease a cough, and nasal saline rinsing is a safe remedy. As a second choice, a cough syrup containing only dextromethorphan could also help a bit, as shown in the Cochrane review. Dextromethorphan is denoted as "DM" on many labels.
6-12: Again, honey-based syrup is not only the most effective but also the safest choice. At this age, the risk-benefit ratio of other treatments becomes more favorable. For nasal congestion, my favorite combination is pseudoephedrine pills and oxymetazoline nasal spray. Probiotics also are helpful.
Don’t forget that many doctors still hesitate to recommend OTC medicines until a child is 12. Also, while oxymetazoline nasal spray works rapidly for nasal congestion, never take it for more than five days in a row. Otherwise, you can develop rebound nasal congestion and you could become dependent on the spray. We call it "Afrin addiction."
12 and up: We're finally at the "adult" age where most OTC medicines are at least safe to use, whether or not they're effective. I would still stick with honey syrup and the decongestants I mentioned above, plus probiotics. Also, don't forget common-sense measures, such as a healthy amount of sleep, foods full of antioxidants and light exercise to boost your immune system. In terms of natural medicines, there’s some evidence that elderberry syrup helps ease flu symptoms.
65 and older: Here we start getting cautious again with OTC medicines. These medicines can cause unwanted side effects in combination with the prescription medications many older people take for chronic diseases. Some OTC medicines also can cause problems by themselves or can intensify existing conditions in the elderly. For instance, pseudoephedrine can worsen high blood pressure, and diphenhydramine can cause confusion, urinary retention and lethargy.
As we get older, we can't fight off infections as well, so it's important to try to stay healthy. Be sure to get the annual flu shot as well as a pneumonia vaccine. If you do get a cold, focus on honey or dextromethorphan syrups, and nasal saline spray for a decongestant.
Avoid homeopathic remedies
Which OTC medicines don't work for people of any age? I would advise against any homeopathic remedies, such as Oscillococcinum or Zicam. They may seem appealing, but there’s absolutely no evidence of effectiveness, as you would expect from a product that by definition has zero molecules of any active drug.
The Federal Trade Commission recently said that homeopathic product labels must effectively communicate “(1) There is no scientific evidence that the product works, and (2) the product’s claims are based only on theories of homeopathy from the 1700s that are not accepted by most modern medical experts."
It’s dangerous to assume that homeopathic remedies are safer than other treatments, as noted by this winter's FDA warnings against homeopathic teething tablets. Tests show the tablets may have toxic amounts of the plant belladonna and could be related to 10 infant deaths. Clearly this is a case where the risks far outweigh any benefits.
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