A pediatrician's cough conundrum
They line up every morning in pediatricians' offices like mine: the 1-month-old whose first cold is making nursing impossible, the 5-year-old whose machine gun cough is keeping the family up all night, the toddler streaming from every orifice - eyes, mouth, nose.
What is a parent to do? What is a pediatrician to recommend? The answer is: not much.
Early this month, just before a hearing by the Food and Drug Administration, drug companies decided to pull from the market 14 multisymptom cold and cough medicines aimed at infants and toddlers. A week later, an FDA advisory panel recommended banning these medications for all children under 6.
Current habits are changing fast, and parental anxiety levels are high.
There are at least 800 different pediatric cold products on the market, many containing multiple ingredients. Some of the complications cited by the drug companies when they pulled the infant formulas were believed to have been caused by parents using multiple medications, not realizing that they had the same ingredient, leading to overdosing.
Dextromethorphan has been implicated in neurologic complications even with proper dosing. Pseudoephedrine, a decongestant, has been linked with high blood pressure, cardiac arrhythmias, and even death. And antihistamines can cause sedation and have also been linked with infant deaths.
Admittedly, in my 30 years as a pediatrician, the only side effects I've seen from these medications - including the ones pulled by drug companies - were occasional sleepless nights (rather than drowsiness) caused by antihistamines.
Another key issue that needs to be resolved: Do any of these medications actually work? The FDA advisory panel suggested they are ineffective for children under 6.
This piece of news may be hotly disputed by some pediatricians and parents, but since many products contain antihistamines, which blissfully put most babies to sleep, it is hard to know if, at the prescribed doses, the ingredients actually reduce cold symptoms.
Not surprisingly, parents are confused. When a 2-month-old patient was ready to receive his first immunizations recently, I advised the mother that he could receive acetaminophen or ibuprofen for fever or pain later that evening. Looking puzzled, the mother queried, "I thought that was banned?" (It's only the multisymptom cold products, not the pain and fever relievers that have been questioned.)
While some parents shield their children from unnecessary drugs, others raised in an if-it-hurts-there-must-be-a-cure mindset demand treatment for each insult. Additionally, parents may sheepishly ask their children's doctor to bless a dose of an antihistamine when embarking on a long airplane journey. (Unless I am traveling on that flight, I try to discourage convenient sedation.)
We surely haven't heard the last from the drug companies in this debate - they simply make too much money from these medications to pull them all off the market. It's not clear when - or if - the FDA will adopt its advisory panel's recommendations, or what the drug companies will do in the meantime.
Personally, I come firmly down on the side of less is more.
All pediatricians want to help their patients and those patients' parents. Unfortunately, there are no good solutions to the six to 10 upper respiratory infections that young children typically get every year - except patience and a loving shoulder.
Sometimes, sick babies will fall asleep in a car seat or toddlers will snooze propped up on lots of pillows. More likely, your child will want to be in your arms.
If your child is feverish or in pain, don't hesitate to give the recommended dose of ibuprofen or acetaminophen. (If you have an infant, you should check with your doctor first.) I think children are entitled to pain relief just like adults.
But both saline drops and bulb syringes used to loosen and suction secretions from the nose make the baby cry. And guess what happens when the baby cries - more secretions!
Cool, moist air is an ideal environment for the respiratory lining in general, but despite frequent recommendations, there are no data to support a benefit to using humidifiers for a cold.
I also don't put much stock in natural remedies for youthful coughs and colds, because I've yet to hear of one that met the evidence-based standards of Western medicine.
And I get nervous when pharmaceutical companies tell parents of young children to "ask your pediatrician" on dosing or safety issues. The companies generally do not want to test medications in young children for liability and ethical reasons. But if they don't know if their drug is safe or how much to give, how should I?
It's depressing, but true: There simply isn't relief for everything. No doubt there'll be more to come on this issue. Until then - a box of tissues, a nursery rhyme, and thee.
Dr. Victoria Rogers McEvoy is chief of pediatrics and medical director of the Mass. General West Medical Group and assistant professor of pediatrics at Harvard Medical School.
