0814 Lancet calls for withdrawal of cough medicines for children

It is probably fair to say that curricula of under- and postgraduate medical students do not support the routine use of cough medicines for treatment of respiratory tract infections in children. Certainly there are indications, for example in the management of pertussis or pertussis-like syndromes, but in general one will not find staff of paediatric in- or out-patient departments prescribing or dispensing these products. Cough and cold medicines will typically contain one or more of the following: nasal decongestants, antihistamines, cough suppressants and expectorants, and while academic teaching discourages routine use of these agents, private practitioners either of their own accord or as a result of parental or caregiver pressure will often include them in their armamentarium. This practice is likely to stop, at least for children <2 years old, as a result of a recent UK Medicine and Healthcare products Regulatory Agency (MHRA) announcement that over-the-counter medicines are no longer suitable for this youngest group. This announcement followed advice from the US Food and Drug Administration after an American analysis and survey identified a few deaths (with pseudoephedrine levels 9-14 times higher than expected after administration of doses that were regarded as being appropriate for 2-12 year olds). The US review also identified some 1500 admissions to emergency departments during 2004 and 2005 that were cough and cold medicine-related, while a survey of 63 hospitals revealed that unintentional overdose is common n children younger than 12. In other words, appropriate dosing, safety and efficacy have not been established for children under 2, and perhaps not for the paediatric population at all. The most important aspect of this debate is therefore not that we must urgently determine the appropriate dosing regimen for the <2’s but rather that we should be asking whether there is evidence that these agents work at all for children, whether above or below 2 years of age. The latter question would appear to have been at least partially answered in a January 2008 Cochrane Review of randomized trials spanning 40 years that concluded that there is no good evidence for or against the effectiveness of over-the-counter medicines in acute cough.

Read more:
Lancet 2008; 371: 1138
http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5601a1.htm (CDC M&M Data) http://www.mrw.interscience.wiley.com/cochrane/clsysrev/articles/CD001831/pdf_fs.html (Cochrane)