Coughs and colds in children By Lynn Greig

Transcription

1 Coughs and colds in children By Lynn Greig Learning objectives After reading this article you should be able to: Discuss the aetiology and transmission of the common cold. Identify symptoms suggestive of a common cold. Provide advice on the use of cough and cold medicines in Discuss the use of complementary medicines for the common cold in Recommend strategies which may help to relieve the symptoms of a cold. Competency standards (2010) addressed: 6.1.1, 6.1.2, 6.2.1, 6.2.2, 6.2.3, Accreditation number: CAP110505a Lynn Greig is a Professional Services Pharmacist with PSA National Office. Case study Mrs Tait, a regular customer, comes into the pharmacy requesting a cough and cold medicine for her four-year-old son, Jimmy. She states that he has had a cold for the past two or three days and describes his symptoms as a runny nose, sneezing, a non-productive cough and a mild fever. She says this is the third cold he has had in the past four months. Why is my son getting so many colds? Children get more coughs and colds than adults. Adults average two to four colds a year, whereas children of pre school age have an average of 12 colds a year. Several colds may occur one after the other. The frequency decreases with increasing age as the immune system develops. Children aged five to nine have an average of four to seven colds per year. Living with smokers increases a child s risk of developing coughs and colds. 1 3 What is causing my son s cold? The common cold can be caused by more than 200 different viruses. Up to 60% of colds are caused by one of more than 100 types of rhinoviruses. Other causative agents include coronaviruses, respiratory syncytial viruses, para-influenza viruses, adenoviruses, enteroviruses, metapneumoviruses, and some Coxsackie and echoviruses. Influenza is an acute upper respiratory infection (URI) caused by influenza viruses of the family Orthomyxoviridae

2 Submit your answers online at and receive automatic feedback Table 1. Influenza or the common cold? 8 Influenza Common cold Spectrum of illness Systemic Local nose and throat Speed of onset Sudden Gradual Fever Usually high Usually mild Main symptoms Chills, fever, muscle aches, malaise, cough, headache, photophobia, sore throat Sneezing, rhinorrhoea, nasal congestion, cough Severity Severe confined to bed Usually mild Course of illness May be prolonged (up to Usually brief (but cough several weeks) may last for 2 3 weeks) How did he catch the cold? Transmission of the common cold is mainly through direct hand contact with secretions from an infected person, object or surface, followed by self-inoculation through touching a mucous membrane (e.g. nose, eye). Rhinovirus can survive for as long as four hours on the hands. Inhalation of infected droplets is a less common method of transmission. Influenza, on the other hand, is transmitted mainly by inhalation of infected respiratory droplets. 3,5 At least 75% of viral upper respiratory infections (URI) are transmitted by This occurs mainly in places where children are in close proximity to each other, e.g. day care centres or classrooms. The children can then transmit the infecting virus to the other members of their family when they return home. 3 How do I know it s only a cold and not influenza? A common cold usually begins with a scratchy or sore throat, followed by sneezing and rhinorrhoea (runny nose). The nasal secretions are initially clear but later become purulent, and nasal congestion may alternate with rhinorrhoea. Children may also develop fever. A non-productive cough develops on day three or four and may later become loose and productive. Most symptoms due to uncomplicated colds resolve within four to 10 days, although some symptoms (particularly cough) may occasionally last for two to four weeks. 3,6 Influenza usually begins with sudden onset of fever, chills, severe malaise, myalgia (especially in the back and legs), dry cough, nasal congestion and a dry, sore throat. Other symptoms may include headache and photophobia. As the infection progresses, the cough may become more severe, persistent, raspy and productive. Children may also have Table 2. Adverse effects of cough and cold medicines 33,34 Class of medicine Cough suppressants Expectorants Sedating antihistamines Decongestants Common adverse effects Drowsiness, constipation, nausea, vomiting, dizziness, restlessness Nausea, vomiting, diarrhoea, dizziness, headache, allergic reactions (e.g. rash, urticaria, angioedema) Drowsiness, dizziness, disturbed coordination, blurred vision, tinnitus, confusion, restlessness, anxiety, nausea, vomiting, diarrhoea, constipation, urinary retention or frequency, dry mouth, wheezing, palpitations, hypotension Oral: CNS stimulation (e.g. restlessness, insomnia, anxiety, tremor, dizziness, hallucinations), arrhythmias, hypertension, skin rash Intranasal: transient burning or stinging, rebound congestion (with prolonged use), sneezing, nausea, headache, insomnia Note: Adverse effects may be more common in young children and elderly people nausea and vomiting. Nasal symptoms generally resolve after two or three days. However, fever sometimes lasts up to five days; and cough, malaise, weakness, sweating and fatigue may persist for several weeks. 3,5,7 (See also Table 1.) What treatment options are available? There are more than 70 cough and cold medicines available in Australia for children, each containing up to four drugs (including cough suppressants, antihistamines, expectorants, decongestants and analgesics/ antipyretics). Dosage of almost all cough and cold medicines for children is based on a formula proposed by the FDA in 1976, i.e. children 6 12 years: ½ the adult dose; children 2 5 years: ¼ the adult dose; and ask your doctor for children aged <2 years. If strictly followed, this system will produce a greater than 3-fold variation in mg/kg dosage between a small two-year-old girl and a big boy who is almost six, and up to a 4-fold variation when the same dose is given to a small 6-year-old girl and a big boy who is almost See Table 2 for a list of some adverse effects of cough and cold medicines. Safety and efficacy of cough and cold medicines in children Opioid cough suppressants (antitussives) No antitussive has been shown to be effective for the treatment of acute cough in It is possible that the lack of efficacy may be due to under-dosing and further research is required to determine appropriate doses in children and whether they are effective and safe at higher doses. 4 Dextromethorphan A 2008 Cochrane review 9 found no evidence for efficacy of dextromethorphan in acute cough in A dosing analysis performed on the sub-group of children who received the active drug in a well-designed clinical trial of dextromethorphan showed a clear trend that the middle and higher doses provided better symptom relief. The study also showed a higher rate of central nervous system (CNS) excitation with higher doses. 377

3 The authors concluded that further studies are needed on higher doses of dextromethorphan in mg/kg, to assess true efficacy and safety. 4,10 Dextromethorphan appears to be relatively safe in overdose. The main adverse reaction is CNS excitation. Seizures may occur at doses of mg/kg. A report of 304 cases of accidental ingestion of dextromethorphan by young children (mean ingested dose 2.64 mg/kg) reported no deaths and only minor effects. 11 Combinations of dextromethorphan and antihistamines or decongestants are likely to be more toxic. Combinations of dextromethorphan and pseudoephedrine have caused a number of adverse effects, including irritability, ataxia and psychosis, in young 4,12 Codeine There are few studies on codeine syrup in One small study comparing placebo, dextromethorphan and codeine in children concluded that codeine syrup was no more effective than placebo. 13 Codeine also causes more adverse effects than other opioidbased antitussives. The American Association of Poison Control Centers (AAPCC) has reported that codeine is the most commonly ingested opioid, in toxic doses, by young Doses greater than 5 mg/kg can produce respiratory and CNS depression. 14 The fact that the metabolism of codeine in children and infants is not well understood adds to the uncertainty and unpredictability of adverse effects. 4 Pholcodine No studies have been done on the effectiveness or safety of pholcodine in Two studies in adults have shown that exposure to pholcodine cough syrup causes a large increase in levels of IgE antibodies towards pholcodine, morphine and suxamethonium. The authors of these studies have recommended restriction of pholcodine because of the risk of future allergic reactions to neuromuscular blocking agents. 4,15,16 Dihydrocodeine There is no efficacy or safety data for dihydrocodeine in 4 Expectorants There is very limited evidence for the efficacy of any of the expectorants in acute cough and no studies have been done in Adult studies on bromhexine found no benefit; and four adult studies on guaifenesin were inconclusive. There have been reports of ammonium chloride toxicity (including metabolic acidbase abnormalities) following abuse of cough mixtures. Bromhexine and guaifenesin appear to have minimal toxicity. 4 Antihistamines One study in children on chlorpheniramine monotherapy for the common cold demonstrated no benefit. 17 A study on dextromethorphan and diphenhydramine for acute cough in children found no benefit of diphenhydramine over placebo. 18 There are no studies of dexchlorpheniramine, pheniramine, promethazine, doxylamine or triprolidine in There are numerous reports of fatal diphenhydramine toxicity in Diphenhydramine is the most cardiotoxic of the antihistamines, as it may cause sodium channel effects and QT prolongation. There have been no reports of toxicity or death in children from monotherapy with the other sedating antihistamines. 4 Decongestants A Cochrane review on oral and nasal decongestants for the common cold found no trials in children and concluded the there is insufficient data to recommend their use in children younger than 12 years of age. 19 (This review was withdrawn in 2009 because the reviewers were unable to update it.) One study of intranasal xylometazoline in children showed that it increases nasal flow, but the study had no control group. 20 Pseudoephedrine has been implicated as the possible cause or a contributory factor in a number of infant fatalities. There is limited data on the safety of phenylephrine. A case series of xylometazoline poisonings in children concluded that the majority of cases caused minimal effects. Severe effects occurred with ingestions >0.4 mg/kg. 21 There is also a report of four cases of oxymetazoline toxicity in Clinical signs included somnolence, sweating, pallor, hypothermia, bradycardia, restlessness, tachycardia, vomiting, irregular breathing and apnoea. 22 Antihistamine-decongestant combinations There have been two studies of antihistamine-decongestant combinations in One study compared a combination of phenylephrine, phenylpropanolamine and brompheniramine to placebo and no treatment, and found no benefit and no difference in side-effects between active and placebo groups. 23 The other study compared brompheniramine and phenylpropanolamine to placebo and found no difference except that children in the active group were more likely to fall asleep within two hours of treatment. 24 These studies both included phenylpropanolamine which has been restricted or withdrawn from the market worldwide and is not available in Australia. There have been numerous reports of adverse effects and toxicity, including dystonic reactions and death, with antihistamine-decongestant combinations in 4 Recommendations The Therapeutic Goods Administration (TGA) has concluded that there is currently a lack of evidence of efficacy for cough and cold medicines in children under 12 years of age, and that the risks of using these medicines in children under six years of age outweigh the likely benefits. They have determined that cough and cold medicines should not be used in children under two years of age. They have also recommended that these medicines should not be used in children under six years of age, and should only be given to children aged 6 12 years on the advice of a doctor or pharmacist. 25 At its June 2010 meeting, the National Drugs and Poisons Schedule Committee (NDPSC) recommended rescheduling 19 substances used in OTC cough and cold medicines to: 26 Schedule 4 (prescription only) for use in children under 2 years of age; Schedule 3 (pharmacist only) for use in children aged from 2 to 6 years; Schedule 2 (pharmacy only) for use in children above 6 years of age and adults. The Advisory Committee on Medicines Scheduling (ACMS), which has replaced the NDPSC, will consider this proposal at their June 2011 ACMS meeting. 378

4 Are there any natural medicines that are effective? Complementary medicines which have been used for the common cold include echinacea, vitamin C and zinc. Each of these has been the subject of a Cochrane review. A Cochrane review on echinacea found no clear evidence of benefit in children for either the prevention or the treatment of the common cold. There were few adverse effects, although rashes were reported in one trial in 27 A Cochrane review of vitamin C found no trials investigating vitamin C for the treatment of the common cold in However, results of trials on regular prophylactic supplementation found a reduction in symptom duration of 13% in children (and 8% in adults). The authors estimated that long-term prophylaxis might produce an average reduction in four symptom days (from 28 to 24 days) per year per child. In addition, one of the prophylactic studies found that, in children, 2 g/day produced about twice the benefit of 1 g/day. None of the trials found evidence that vitamin C might be harmful in the doses that were tested. The review authors recommend further trials be carried out to test the benefits of therapeutic supplementation in children, using doses of at least 2 g per day. 28 A recently updated Cochrane review found that zinc, when administered within 24 hours of onset of symptoms, reduced the duration and severity of the common cold. When children were given zinc supplements for at least five months, they had reduced cold incidence, school absenteeism and prescriptions for antibiotics. However, zinc lozenges (but not syrup or tablets) produced adverse effects, including bad taste and nausea. The reviewers concluded that, in view of the differences in study populations, dosages, formulations and duration of treatment, more research is needed before a definitive recommendation can be made. 29 Is there anything else I can do to help? The following strategies may help to relieve cold symptoms: 2,6,30,31 To avoid dehydration, encourage the child to drink plenty of fluids. Frequent, small drinks may be easier for the child to manage. Saline nasal spray or drops (e.g. Fess, Narium) may help to relieve nasal congestion while avoiding the risk of rebound congestion from use of a topical nasal decongestant. Steam inhalations may help clear mucus and relieve blocked sinuses. Children should only inhale steam from a shower, as steam from a bowl of hot water can burn the lining of a child s nose. Paracetamol can be given in appropriate doses if the child has a sore throat or fever. Ibuprofen may be an alternative for children over six months of age. Aspirin should not be given to children under 18 years of age due to the risk of Reye s syndrome. Avoid exposing the child to cigarette smoke. Should I take my child to the doctor? If children develop any of the following symptoms they should be taken to the doctor: a temperature >38.5 o C; chills; a stiff neck; severe headache; photophobia; chest pain; a skin rash; a persistent cough; fast or noisy breathing or difficulty breathing; vomiting; pale or mottled skin; unusual drowsiness; or earache. Additional triggers for referral in a baby include bulging of the fontanelle; a strange, high-pitched cry; irritability or lethargy; and refusal to feed. 2,31,32 Case study Mrs Tait can be reassured that a child of Jimmy s age can get as many as 12 colds a year, but that the colds should decrease in frequency as he gets older. Jimmy s symptoms are consistent with a common cold but, if he develops any of the alarm symptoms listed above, or if his symptoms show no improvement within the next two or three days, she should take him to the doctor. Because the common cold is caused by a virus, antibiotics will be of no benefit. In addition, because there is insufficient evidence that cough and cold medicines or herbal medicines are effective in children, but may cause adverse effects, it is preferable not to use them. Mrs Tait can give Jimmy some paracetamol syrup (at an appropriate dose for his age and weight) to relieve fever and sore throat. Saline nose drops may also be used to help clear his nasal congestion. Key learning points The common cold can be caused by more than 200 different viruses. Colds are most commonly acquired through direct hand contact, with inhalation of infected droplets being a less common mode of transmission. Cold symptoms include a sore throat, sneezing, rhinorrhoea, nasal congestion and a non-productive cough which may later become loose and productive. Most symptoms resolve within four to 10 days, although cough may persist for up to three weeks. There is currently little evidence that cough and cold medicines are effective in The TGA has determined that these medicines should not be used in children under two years of age. They have also recommended that these medicines should not be used in children under six years of age, and should only be given to children aged 6 12 years on the advice of a doctor or pharmacist. Paracetamol and saline nasal drops or spray may help to relieve some cold symptoms in a child. References 1. Medicines and Healthcare products Regulatory Agency (MHRA). Overview risk : benefit of OTC cough and cold medicines in children [online]. At: uk/home/idcplg?idcservice=get_file&ddocname=co N041374&RevisionSelectionMethod=LatestReleased 2. Coughs and Colds in Children. Patient UK information leaflet [online]. At: 3. Pray, WS. Nonprescription product therapeutics. 2nd edn. Lippincott Williams & Wilkins; Therapeutic Goods Administration. Review of cough and cold medicines in children [online]. Apr Australian Government, Department of Health and Ageing. At: 5. Sweetman S, ed. Martindale: The Complete Drug Reference. 36th edn. London: Pharmaceutical Press; National Prescribing Service. NPS News 63: Managing expectations for antibiotics in respiratory tract infections [online]. At: health_professionals/publications/nps_news/current/ nps_news_63 7. Merck Manual for Healthcare Professionals [online]. At: 8. I nfluenza: a guide for pharmacists [online]. The Influenza Specialist Group: Richmond Vic; At: www. influenzacentre.org/reports/pharma_06.pdf 9. Smith SM, Schroeder K, Fahey T. Over-the-counter (OTC) medications for acute cough in children and adults in ambulatory settings. In: Cochrane Database of 380

5 Submit your answers online at and receive automatic feedback Systematic Reviews 2008, Issue 1 [online]. At: onlinelibrary.wiley.com/o/cochrane/clsysrev/articles/ CD001831/frame.html 10. Paul IM, Shaffer ML, Yoder KE, et al. Dose-response relationship with increasing doses of dextromethorphan for children with cough. In: Clin Ther. 2004; 26: [online]. At: S %2804% /pdf 11. LoVecchio F, Pizon A, Matesick L, et al. Accidental dextromethorphan ingestions in children less than 5 years old. J Med Toxicol. 2008; 4: Roberge RJ, Hirani KH, Rowland PL, et al. Dextromethorphan- and pseudoephedrine-induced agitated psychosis and ataxia: case report. J Emerg Med. 1999; 17: Taylor JA, Novack AH, Almquist JR, et al. Efficacy of cough suppressants in children [online]. J Pediatr. May 1993; 122(5 Pt 1): At: pubmed/ Gharahbaghian L, Lopez N, Oman JA. Toxicity, Cough and Cold Preparation [updated Sep 2009]. In: emedicine [online]. At: article/ overview 15. Harboe T, Johansson SG, Florvaag E, et al. Pholcodine exposure raises serum IgE in patients with previous anaphylaxis to neuromuscular blocking agents. In: Allergy 2007; 62: [online]. At: onlinelibrary.wiley.com/doi/ /j x/full 16. Florvaag E, Johansson SG, Oman H, et al. Pholcodine stimulates a dramatic increase of IgE in IgE-sensitized individuals. A pilot study. In: Allergy. 2006; 61:49 55 [online]. At: j x/full 17. Sakchainanont B, Ruangkanchanasetr S, Chantarojanasiri T, et al. Effectiveness of antihistamines in common cold. J Med Assoc Thai. 1990; 73: Questions 1. Which of the following statements regarding the common cold is CORRECT? a) The most frequent causative agents of the common cold are respiratory syncytial viruses. b) The common cold is usually acquired through inhalation of infected droplets. c) Passive smoking increases a child s risk of catching colds. d) The viruses which most frequently cause the common cold can survive for up to eight hours on a person s hands. 2. Regarding the symptoms of the common cold, which of the following statements is CORRECT? a) Most symptoms of the common cold generally resolve within four to 10 days. b) Adults, but not children, often develop a high fever with a common cold. c) A common cold usually begins with sudden onset of fever, chills and muscle aches. 18. Yoder KE, Shaffer ML, La Tournous SJ, et al. Child assessment of dextromethorphan, diphenhydramine, and placebo for nocturnal cough due to upper respiratory infection. Clin Pediatr. Sep 2006; 45(7): [online]. At: content/45/7/ Taverner D, Latte GJ. Nasal decongestants for the common cold. Cochrane Database of Systematic Reviews 2007, Issue 1 [online]. At: wiley.com/o/cochrane/clsysrev/articles/rel0003/ CD001953/frame.html 20. Pickering DN, Beardsmore CS. Nasal flow limitation in Pediatr Pulmonol. 1999; 27: Van Velzen AG, van Riel AJ, Hunault C, et al. A case series of xylometazoline overdose in Clin Toxicol (Phila). 2007; 45:290 4 [online]. At: abs/ / Bucaretchi F, Dragosavac S, Vieira RJ. Acute exposure to imidazoline derivatives in J Pediatr (Rio J). 2003; 79: [online]. At: v79n6/en_v79n6a10.pdf 23. Hutton N, Wilson MH, Mellits ED, et al. Effectiveness of an antihistamine-decongestant combination for young children with the common cold: a randomized, controlled clinical trial. J Pediatr. 1991; 118: [online]. At: Clemens CJ, Taylor JA, Almquist JR, et al. Is an antihistamine-decongestant combination effective in temporarily relieving symptoms of the common cold in preschool children? J Pediatr. 1997; 130: TGA internal panel report on the safety, efficacy and use of cough and cold medicines in the treatment of children aged 2 12 years. May 2009 [online]. At: d) One of the early symptoms of a common cold is a productive cough which later becomes dry and non-productive. 3. Which of the following statements regarding the use of cough and cold medicines in children is CORRECT? a) The TGA has determined that cough and cold medicines should not be used in children under 12 years of age. b) There is good evidence for the efficacy of expectorants in adults, but not in c) There have been several reports of fatal dexchlorpheniramine toxicity in d) There is some evidence that the efficacy of dextromethorphan in children may be dose-dependent. 4. Which of the following statements regarding the use of herbal medicines for colds in children is CORRECT? a) Echinacea has been found to be effective for preventing, but not treating, colds in 26. Interim decisions & reasons for decisions by the Delegate of the Secretary to the Department of Health and Ageing. February 2011 [online]. At: au/pdf/scheduling-decisions-1102.pdf 27. Linde K, Barrett B, Bauer R, et al. Echinacea for preventing and treating the common cold. Cochrane Database of Systematic Reviews 2006, Issue 1 [online]. articles/cd000530/frame.html 28. Hemilä H, Chalker E, Douglas B. Vitamin C for preventing and treating the common cold. Cochrane Database of Systematic Reviews 2007, Issue 3 [online]. articles/cd000980/frame.html 29. Singh M, Das RR. Zinc for the common cold. Cochrane Database of Systematic Reviews 2011, Issue 2 [online]. articles/cd001364/frame.html 30. National Prescribing Service. Information: Common colds need common sense, not antibiotics [online]. Jul At: ccncs/brochure 31. Kemp CA, McDowell JM, eds. Paediatric Pharmacopoeia. 13th edn. Pharmacy Department, Royal Children s Hospital, Melbourne; Better Health Channel. Colds explained.[updated Feb 2010] [online]. At: bhcarticles.nsf/pages/colds_explained 33. Rossi S, ed. Australian Medicines Handbook. Adelaide: Australian Medicines Handbook [online]; Jan Approved product information. emims [online]. St Leonards: CMPMedica Australia; Dec A score of 4 out of 5 attracts 1 CPD credit. b) There is some evidence that longterm zinc supplementation may reduce the incidence of colds in c) Long-term vitamin C supplementation has not been found to be effective in reducing the duration of cold symptoms in d) Lozenges are the preferred dosage form for zinc supplementation in 5. Which of the following is an APPROPRIATE recommendation for relieving the symptoms of colds in children? a) Allow the child to inhale steam from a bowl of hot water. b) Aspirin can be given in appropriate doses for a sore throat or fever. c) Saline nasal drops may relieve nasal congestion, but there is a risk of rebound congestion with prolonged use. d) Encourage the child to have frequent small drinks, to avoid dehydration. 381