Over-the-counter cough and cold preparations: Approach to pediatric poisoning
- Shan Yin, MD, MPH
Shan Yin, MD, MPH
- Assistant Professor of Pediatrics, University of Cincinnati School of Medicine
- Division of Emergency Medicine, Cincinnati Children's Hospital
- Medical Director, Cincinnati Drug and Poison Information Center
- Section Editor
- Michele M Burns, MD, MPH
Michele M Burns, MD, MPH
- Section Editor — Pediatric Toxicology
- Assistant Professor of Pediatrics
- Harvard Medical School
- Deputy Editor
- James F Wiley, II, MD, MPH
James F Wiley, II, MD, MPH
- Senior Deputy Editor — Adult and Pediatric Emergency Medicine
- Senior Deputy Editor — Primary Care Sports Medicine (Adolescents and Adults)
- Professor of Pediatrics and Emergency Medicine/Traumatology
- University of Connecticut School of Medicine
Orally administered over-the-counter (OTC) cough and cold medications contain a variety of active ingredients including acetaminophen, antihistamines, dextromethorphan, decongestants (eg, alpha adrenergic agonists such as phenylephrine or pseudoephedrine), and ethanol. These medications frequently cause significant toxicity in children younger than six years of age.
Topical agents, such as imidazoline ophthalmic and nasal drops (eg, tetrahydrozoline or oxymetazoline), and camphor containing products are also frequently used to control cough and cold symptoms and can have major toxicity.
The approach to pediatric poisoning from OTC cough and cold medication in children will be reviewed here. The toxicity to children posed by individual ingredients (eg, acetaminophen, dextromethorphan, imidazolines, or camphor) and the use of cough and cold medications in children are discussed separately:
●(See "Clinical manifestations and diagnosis of acetaminophen (paracetamol) poisoning in children and adolescents" and "Management of acetaminophen (paracetamol) poisoning in children and adolescents".)
●(See "Anticholinergic poisoning".)
- US Food and Drug Administration. Public Health Advisory: FDA recommends that over-the-counter (OTC) cough and cold products not be used for infants and children under 2 years of age. http://www.fda.gov/drugs/drugsafety/postmarketdrugsafetyinformationforpatientsandproviders/drugsafetyinformationforheathcareprofessionals/publichealthadvisories/ucm051137.htm (Accessed 12/31/13).
- Kuehn BM. Debate continues over the safety of cold and cough medicines for children. JAMA 2008; 300:2354.
- Budnitz DS, Lovegrove MC, Rose KO. Adherence to label and device recommendations for over-the-counter pediatric liquid medications. Pediatrics 2014; 133:e283.
- Vernacchio L, Kelly JP, Kaufman DW, Mitchell AA. Cough and cold medication use by US children, 1999-2006: results from the slone survey. Pediatrics 2008; 122:e323.
- Cough and cold remedies for the treatment of acute respiratory infections in young children. Department of Child and Adolescent Health and Development. World Health Organization. 2001. Available at http://www.who.int/maternal_child_adolescent/documents/fch_cah_01_02/en/ (Accessed March 5, 2014).
- Mowry JB, Spyker DA, Brooks DE, et al. 2014 Annual Report of the American Association of Poison Control Centers' National Poison Data System (NPDS): 32nd Annual Report. Clin Toxicol (Phila) 2015; 53:962.
- Centers for Disease Control and Prevention (CDC). Infant deaths associated with cough and cold medications--two states, 2005. MMWR Morb Mortal Wkly Rep 2007; 56:1.
- Dart RC, Paul IM, Bond GR, et al. Pediatric fatalities associated with over the counter (nonprescription) cough and cold medications. Ann Emerg Med 2009; 53:411.
- Kelly LF. Pediatric cough and cold preparations. Pediatr Rev 2004; 25:115.
- Manoguerra AS, Erdman AR, Wax PM, et al. Camphor Poisoning: an evidence-based practice guideline for out-of-hospital management. Clin Toxicol (Phila) 2006; 44:357.
- Gunn VL, Taha SH, Liebelt EL, Serwint JR. Toxicity of over-the-counter cough and cold medications. Pediatrics 2001; 108:E52.
- Tomassoni AJ, Weisman RS. Antihistamines and decongestants. In: Goldfrank's Toxicologic Emergencies, 9th edition, Nelson LS, Lewin NA, Howland MA, et al. (Eds), McGraw Hill Medical, New York 2011. p.748.
- Cole JB, Stellpflug SJ, Gross EA, Smith SW. Wide complex tachycardia in a pediatric diphenhydramine overdose treated with sodium bicarbonate. Pediatr Emerg Care 2011; 27:1175.
- Mazer-Amirshahi M, Reid N, van den Anker J, Litovitz T. Effect of cough and cold medication restriction and label changes on pediatric ingestions reported to United States poison centers. J Pediatr 2013; 163:1372.
- Lokker N, Sanders L, Perrin EM, et al. Parental misinterpretations of over-the-counter pediatric cough and cold medication labels. Pediatrics 2009; 123:1464.
- Hanoch Y, Gummerum M, Miron-Shatz T, Himmelstein M. Parents' decision following the Food and Drug Administration recommendation: the case of over-the-counter cough and cold medication. Child Care Health Dev 2010; 36:795.
- Lazarus SG, Lanski SL, Smith AS, Simon HK. Cold preparation use in young children after FDA warnings: do concerns still exist? Clin Pediatr (Phila) 2013; 52:534.
- Oral agents
- Topical agents
- TOXICITY BY INGREDIENT
- Phenylephrine and similar decongestants
- Tetrahydrozoline and similar imidazolines
- ADDITIONAL RESOURCES
- SUMMARY AND RECOMMENDATIONS