Everything you need to know about cough medications

Your child’s been doing a valiant job of battling a nasty cold and is now tucked contentedly into bed. But soon you hear a cough or two, then a prolonged coughing spell, which leads to another, and another and before long, it’s clear that no one will be getting much sleep tonight. What to do?

Dealing with a persistent cough can be frustrating, and adding to that frustration is the mind-boggling array of over-the-counter cough medications available in drugstores and grocery stores. You’ll likely be faced with 20 or more different preparations for various problems, such as cough and cold, cough and sore throat, chest congestion, nighttime, dry or stubborn cough, in everything from junior strength to extra strength, and in every mode from flavoured syrups to medicated candies and frozen pops. It’s a huge market: In 2003, Canadians coughed up about $132.5 million for these remedies, according to the NDMAC, the association that represents manufacturers of over-the-counter medications in this country.

The selection on the store shelves may seem overwhelming, but in fact there are only two main types of cough and two major ingredients to treat them. The more common kind of cough is “non-productive” — a dry hack caused by a persistent tickle in the back of the throat. It doesn’t produce much phlegm, although persistent dry coughing may cause a child to vomit. The other type, which is rare in children, is a productive cough, caused by mucous that needs to be expelled from the chest.
Since non-productive coughs don’t have a medical purpose — the only thing they produce is a vicious circle of more coughing — they can safely be suppressed. By far the most popular ingredient used as a cough suppressant is dextromethorphan, or DM. For productive coughs, the major ingredient is guaifenesin, an expectorant that helps you expel mucous from your respiratory tract so you can spit it out. While both DM and guaifenesin have been shown to be modestly effective in adults, there have been few studies to determine whether they work in kids. One recent study actually found that a simple syrup was just as effective (see “Do They Work?”).

Some cough medicines — often labelled “extra strength” — contain both a suppressant and an expectorant. “It’s an irrational combination,” says paediatrician and pharmacologist Michael Rieder, head of clinical pharmacology at the Children’s Hospital of Western Ontario in London. Rieder says it doesn’t make sense for a medication to both suppress a cough and make you cough up phlegm.

The best and safest cough remedies are the ones with only one active ingredient, says George Murray, a pharmacist from Sackville, NB, and incoming president of the Canadian Pharmacists Association. Increasingly, cough syrups are combining at least two — and up to five — active ingredients, such as diphenhydramine (an antihistamine); pseudoephedrine (a decongestant, which may cause restlessness or troubling dreams); and acetaminophen (a pain reliever). “There’s a danger of giving a child too much medication — say, Tylenol on top of a multi-symptom product that already contains acetaminophen, or antihistamine when they don’t need one,” says Murray. “Stick with a single-purpose product.” Administering medications separately helps parents target specific symptoms, he says. For instance, if your child has a headache and cough and you’re giving Tylenol and cough medication separately, you can stop the Tylenol when it’s no longer needed and simply continue with the cough medication.
Don’t use any over-the-counter cough remedy on children under age two without consulting a physician, and don’t use on older children for more than three days without talking to a pharmacist or physician. Store according to package instructions and check expiry dates. Treating a cough is not an exact science, but here are some guidelines for your next late-night run to the drugstore.

Type of cough: Non-productive.
Symptoms: Dry, hacking cough with little phlegm. There may be some rattly noises in the chest, not because of excess mucous but because children’s small airways may be irritated and swollen.
Ingredient to look for: Dextromethorphan (DM).
How it works: It prevents the brain from interpreting the throat “tickle” as a need to cough.
Some products containing DM: Benylin DM Stubborn Cough For Children, Benylin DM Freezer Pops, Benylin Dry Cough, Delsym. DM is the only active ingredient in all these.
Dosage: The most effective dose for children is not known, but follow age-based guidelines on the package or consult your pharmacist.
Possible side effects: Restlessness, drowsiness, stomach upset.
Who shouldn’t use it: Anyone with asthma. Discuss any underlying disease, such as diabetes or a thyroid condition, with your child’s doctor before use.

Type of cough: Productive.
Symptoms: Excessive amounts of thick mucous coming from the chest.
Ingredient to look for: Guaifenesin.
How it works: Helps to thin mucous, making it easier to cough up.
Some products containing guaifenesin: BenylinE, Robitussin Liquid, Sudafed Cold & Flu, Buckley’s Jack & Jill. (BenylinE is the only one that contains only guaifenesin as an active ingredient.)
Dosage: The most effective dose for children is not known, but follow age-based guidelines on the package or consult your pharmacist.
Possible side effects: Occasionally diarrhea, headache, dizziness, nausea, heartburn, stomach ache and sweating.
Who shouldn’t use it: Those with sensitivity to guaifenesin (diarrhea, dizziness, headache, hives, nausea, vomiting, skin rash, stomach pain). Discuss any underlying disease, such as diabetes or a thyroid condition, with your doctor before use.
Do They Work?
In a study published last July, researchers at Pennsylvania State College of Medicine took 100 children with coughs and sleep problems caused by upper respiratory infections, and divided them into three groups. One group received the cough suppressant dextromethorphan (DM); another group got the antihistamine diphenhydramine; and the third group was given a placebo.

The surprising result: Parents reported that the frequency and severity of the cough and the sleep quality for both their children and themselves improved significantly in all three groups. The children receiving the placebo did just as well as those getting the real medicine, and with fewer side effects. The kids who took DM reported more insomnia, those on diphenhydramine more drowsiness.

Perhaps the power of suggestion had an effect on the children. (In another 2004 study, from SUNY Upstate Medical University in New York, 40 of 51 children were free of their persistent coughs after a single session in self-hypnosis.) Or maybe the coughs would have disappeared on their own anyway. Understandably, many parents feel desperate for temporary relief so the whole family can get some sleep, but remember that even without any treatment, most children’s coughs clear up in a few days, says London, Ont., paediatrician and pharmacologist Michael Rieder.

When to Act
It can be tricky figuring out whether a child with a cough needs a little TLC, a dose of medicine or a visit to the doctor. Above all, trust your instincts. When in doubt, refer to this guide:

Your child probably doesn’t need cough medicine if:
• the cough and other symptoms aren’t severe;
• he is alert during the day;
• he is normally healthy;
• he is sleeping well (even if you are not).
Continue to give lots of fluids, encourage extra rest and use a cool-mist vaporizer and/or a saline nasal preparation to relieve stuffy nose.

You may want to use cough medicine if:
• the symptoms aren’t severe, but a nagging nighttime cough is disturbing sleep.
Stick to a product with dextromethorphan as the only active ingredient.

Call the doctor the next day if:
• the nagging nighttime cough is accompanied by a low fever, which is relieved by acetaminophen.

Call the doctor immediately if:
• the cough is accompanied by quick onset of severe symptoms including high fever, neck pain, laboured breathing, general
malaise or lethargy, which could indicate a serious infection such as pneumonia, respiratory syncytial virus or meningitis.
• if your child has other medical conditions that put him at risk, such as asthma or bronchitis.

Cough Med Abuse
While safe when taken as directed, in large quantities dextromethorphan (dubbed dex, DXM and “syrup” by recreational users) can produce hallucinations and out-of-body sensations. It may also cause a spike in blood pressure, irregular heartbeat, seizures and brain damage.

In the world of drug abuse, cough syrup is only a minor player — albeit a cheap and readily available one. Still, the RCMP in Vancouver suggest that finding empty cough syrup bottles should alert you to a teen’s potential drug problem.

Getting high on cough medicine is nothing new. Over a hundred years ago, heroin was marketed as a cough medicine for children. A generation ago, the narcotic codeine was common in over-the-counter cough syrups.

Off the Market
Cough and cold products containing phenylpropanolamine (PPA), a decongestant, were withdrawn from the Canadian market in 2001, after a Health Canada assessment determined a possible, though extremely rare, link between PPA and haemorrhagic stroke.