Safe and Effective Cough and Cold Treatment for Children Under Four

Watching your young child suffer through a cold or flu virus is a particularly insidious form of torture. The snot, the ragged breathing, the pervasive crankiness. To add to the misery, the primary caregiver and snot wiper (in our family's case, me) often catches the same bug. The caregiver, however, has the option of taking drugs to alleviate the symptoms. A couple teaspoons of Tussin and I'm good to go, or at least able to breathe again. Not so for my little guy. The warning labels on children's cough and cold medicine have changed since my days in child care, strongly advising us not to administer doses to kids under four.

If you're anything like me, you wonder why. What happened in the past few years to change these products from helpful symptom relief to little-kid poison? Don't these things help children to sleep, breathe, and just plain feel better? What prompted the American Association of Pediatrics to change their guidelines  and what can we do to help our little sickie-poos feel better?

Which cough and cold medicines are affected by the new guidelines?

Antihistamines, decongestants, antitussives (cough suppressants), and expectorants. These active ingredients are found in a wide variety of products marketed for relief of cough and cold.

Pain relievers/fever reducers such as acetaminophen (Tylenol) and ibuprofen (Advil) are still okay for use in infants and small children, provided doses are measured properly.


Why did the AAP make these changes?

According to an FDA advisory panel, these products are ineffective and potentially hazardous when given to small children. There is not enough evidence of efficacy to justify the risk of adverse reaction or overdose.


Ineffective? But doesn't it make kids feel better, or at least help them sleep?

Intuitively, this seems to make sense. The caregiver doses the miserable, crying, phlegmy child with medicine and, usually within the hour, the child becomes drowsy and seems to breathe more easily. The medicine must have worked, right?

Not necessarily. The caregiver has fallen prey to the post hoc ergo propter hoc fallacy--in other words, he or she has confused correlation with causation. I admit I've fallen for this one myself; it's easy to attribute the seeming regression of symptoms to the administration of a drug. However, viral illness is not a fixed, static state. Symptoms fluctuate, with peaks of misery followed by valleys of relative improvement. Chances are, the kid would have calmed down and fallen asleep regardless, with or without the medicine.

In fact, one study comparing dipenhydramine (Benadryl) and dextromethorphan (cough suppressant) to a placebo found that cough and cold medicines are not effective in providing nocturnal symptom relief for children, nor do they improve quality of sleep for their parents. In other words, the family of a sick kid will be awake and miserable whether the kid is medicated or not. But there is a silver lining to this bummer of a study--all families in the study reported significant improvement on the second night, regardless of whether the children were given placebos or drugs.


Are cough and cold medicines really dangerous? 

Not if administered properly; most adverse reactions are due to dosing errors and accidental ingestion. If parents are diligent about measuring doses (and can tell a mL from a tsp), and always keep medicines out of reach, that shouldn't be a problem. Unfortunately, a recent study shows that parents are quite likely to incorrectly measure a dose (especially with the little plastic measuring cups--oral syringes are far more accurate), usually giving more than the recommended amount. In fact, emergency rooms visits for "adverse events" (i.e. overdoses) decreased substantially after the withdrawal of infants' cough and cold formulas from the market.


What about alternative remedies? Are they safe and effective?

While many people swear by Airborne, Oscillococcinum, and Zicam, there is no credible evidence that these products work as advertised.  Not only are they ineffective for symptom relief beyond the placebo effect, but they can also have serious side effects. Airborne containsVitamin A, which is toxic in high amounts. The makers of Zicam were sued and settled out of court after their product caused more than 130 people to lose their sense of smell. And a homeopathic remedy like Ocsillococcinum poisoned children after manufacturing errors led to an excess of an active ingredient (usually active ingredients are diluted until not a trace molecule remains, as in all "true" homeopathic remedies). Considering the typically high price of these products, there seems to be very little benefit to justify the risks.


What can I do to help my poor baby feel better? 

Medically speaking, not much. Cool-mist humidifiers can help ease congestion. If you're brave (and your child will let you), you can use a bulb aspirator to suck snot from the nostrils (be sure you're using it correctly so you don't puff air up there). You can also use saline drops to soothe and loosen the sinuses, and children's Vapo-Rub to help the child breathe (though this is not recommended for children under 2 because of the toxicity of camphor if ingested and the possibility of skin irritation).

Mostly, you just need to be patient. Kids get 6-10 colds a year on average, which tend to last up to two weeks at a time. That's a lot of snotty nights and grouchy days. But if you keep your child hydrated, well-fed, and comfortable, he or she will get better in a reasonable amount of time. Short of keeping children in a plastic bubble, there is no reliable way to prevent or cure occasional viral outbreaks. We just have to get through them the best we can. Children under four should be doing that without the aid of medication.

It's tempting to head to the drug store to buy something, anything, that will help our sick kids. It makes us feel in control, like we're being proactive and doing something to make what's wrong right again. But beyond that fleeting feeling of being a "good" parent, very little is gained from the purchase and administration of over the counter cough and cold remedies.