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Journalism of Courage
It’s 2 pm and while the crowd is thinning out at every OPD, four children and their parents are awaiting their turn outside the paediatric one. All of them are under four years of age and have developed fever, cough and cold due to a sudden change in temperature. Dr Nameet Jerath, paediatric pulmonology and critical care specialist, has his hands full tending to children with upper respiratory infections, allergies and viral fevers. All of them have different kinds of coughing bouts — whooping, wheezing, wet, dry, barking, hissing and retching. Still, he refrains from prescribing any cough syrup.
A mother says her three-year-old has a stubborn cough although his fever had subsided two days ago and that’s giving her sleepless nights. He prescribes a round of nebulisation, which her toddler can tolerate better than steam, but doesn’t administer a cough syrup. “Children under four really do not need it as it is not as effective as thought. Except for offering fleeting comfort, there is no scientific evidence that these cough syrups work in this age group. So there’s no point giving them at all,” he adds. A study published in the Journal of the American Medical Association (JAMA) early this year confirmed that over-the-counter cough medicines offer no proven benefit for children’s coughs.
Besides, most infections in children are viral, self-limiting and the discomfort eases once the child recovers. “Syrup or not, the child is going to get better anyway,” says Dr Jerath. “Very rarely, may be in a subset of patients, we might use cough syrup very judiciously and under supervision to relieve severity of symptoms,” he adds.
This caution comes amid the child deaths in Madhya Pradesh and Rajasthan due to contaminated cough syrups. The Directorate General of Health Services (DGHS) has also issued an advisory to all states and Union Territories on the rational use of cough syrups in children, following consumption-related deaths in Madhya Pradesh and Rajasthan. While the contaminated syrups have led to kidney complications in infants and toddlers in affected states, even the most common ingredient in cough syrup, dextromethorphan hydrobromide, is known to cause side effects in children when the dosing isn’t appropriate.
Also, since cough syrups are easily available over-the-counter, parents may not be aware of the strict dosing that they require. No cough syrup should be used unless prescribed by the doctor. That too, not beyond the days mentioned in the prescription.
What’s the verdict on dextromethorphan hydrobromide?
It is a common ingredient in numerous cough syrups intended for the control of dry cough due to its effects on the cough centre in the brain. It is generally safe and effective when given as instructed for adults. However, when not taken as recommended, dextromethorphan hydrobromide can pose a risk, particularly among children. Children are more vulnerable to even small overdoses because they are in stages of development and their organs have not matured.
Why cough syrups are not a must for children
Dr Jerath attributes most coughing bouts in children to nasal allergies and posterior nasal drips, when mucus from the nose and sinuses drips down the back of the child’s throat. “Such children will then need anti-allergic medication, not a cough syrup. Besides, most of these syrups are cough suppressants. This can sometimes be harmful in children. Suppressing the cough means the secreted mucus might just accumulate in the chest and worsen the infection,” says Dr Jerath. Coughing is a healthy and necessary reflex that helps clear mucus and irritants from a child’s airways. Suppressing this reflex with medication can be counterproductive.
Certain home remedies can be relieving like normal saline nebulisation, hydration, using humidifiers and warm honey water, the latter soothing itchiness, and propping up the child’s head while sleeping. “It is a question of just keeping the child comfortable. Only a rare group of children would need something more than these remedies. Only in these circumstances can a cough syrup be used depending on the diagnosis of the trigger, inflammation and blocked airways. We may be worrying about dextromethorphan hydrobromide, which can make a child drowsy with improper dosing. But even common anti-allergic medicines are not without their side effects. Antihistamines can be sedating and thicken mucus, making it difficult for the child to cough out and clear their chest. Every drug needs to be carefully administered to a child,” says Dr Jerath, who relies a lot on nebulisation as a safe intervention.
Why dosing can be a problem for children
Another rather serious consideration revolves around inappropriate dosing or use. “Giving adult formulations to children, or exceeding the recommended dose for a child, can result in significant and potentially fatal complications. Furthermore, children with unrecognised medical conditions would be more susceptible to a side effect from the syrup,” says Dr Jain.
Taking too much dextromethorphan hydrobromide can potentially result in some serious side effects, including sleepiness, fast heart rate, seizures, liver damage or trouble breathing. In extreme cases, it may lead to coma or death. Even in recommended amounts, infants and children may have some negative reactions to the drug because their bodies are not able to metabolise it properly.
This has resulted in many children landing in emergencies. Dr Jerath has seen children in a very drowsy state, breathing shallow and heavy. “Cough syrup use is associated more with the perception of parents than the condition of the child,” he says.
Caregivers can accidentally give a child an overdose of a combination drug. The same active ingredient may be present in both single and combination drugs, leading to an overdose.
Why is your baby coughing?
Your baby could be allergic to pet dander, dust, mold and other household allergens. If your baby tends to cough while trying to fall asleep at night but isn’t sick, then chances are they have asthma, a chronic inflammatory disease of the airways.
Everything from respiratory viruses like a cold, flu, or croup to bacterial infections such as bronchitis, pneumonia, and whooping cough can trigger coughing in babies. This is usually due to an increase in mucus in the throat or lungs, or sometimes because of inflamed or irritated bronchial tissue. Some babies are prone to gastroesophageal reflux disease (GERD), which can cause coughing and gagging as stomach acid irritates the throat.
