Restricting cough and cold medicines in children

Nationwide epidemiology and health resource use among children with COVID-19 in Japan

BACKGROUND

The COVID-19 pandemic posed substantial challenges to healthcare systems. Understanding the responses of pediatric health services is crucial for future pandemic planning and preparedness, yet such data remains limited.

METHODS

In this retrospective cohort study, we analyzed data from administrative databases developed by Japan Medical Data Center and DeSC Healthcare Inc. The dataset comprised records of 2,612,511 children, totaling 60,224,888 person-months, from January 2020 to May 2022. Multivariate generalized estimation equations were used to examine the incidence rates of COVID-19 and associated health resource use.

RESULTS

Our analysis revealed that the incidence rates of COVID-19 gradually increased from Wave I (2.2 cases per 100,000 person-months) to Wave V (177.8cases per 100,000 person-months), with a notable elevation during Wave VI (2367.7 cases per 100,000 person-months). While nucleic acid amplification tests were primarily used during Waves I-V, the use of rapid antigen tests markedly increased in Wave VI. The hospitalization rates increased gradually from 0.2 in Wave I to 10.2 events per 100,000 person-months in Wave VI, and the case-hospitalization risk decreased from 14.9% in Wave II to 0.7% in Wave VI. Additionally, we observed decreasing trends in the use of antibiotics (Wave I, 31.8%; Wave VI, 9.0%), whereas antipyretic use rose from Wave I (56.1%) to Wave VI (86.6%).

CONCLUSIONS

Our study highlighted essential changes in the nationwide pediatric healthcare system's response to the COVID-19 pandemic. These findings provide valuable insights into the future pandemic planning and preparedness.

Clinical Toxicology of OTC Cough and Cold Pediatric Medications: A Narrative Review

Cough and cold symptoms (CCS) are common pediatric conditions often treated with over-the-counter (OTC) medications. However, the available knowledge regarding the safety and toxicity of these medications in children is inadequate. Therefore, understanding their clinical toxicology is crucial for safeguarding children's well-being. This narrative review highlights the importance of clinical toxicology in evaluating the safety and toxicity profile of OTC medications for treating CCS in pediatric patients. The pharmacology, clinical features, and adverse effects of various drug classes commonly found in cough and cold medications are briefly discussed. Pharmacokinetic and pharmacodynamic parameters are also examined to understand the interactions between these drugs and the body. OTC cough and cold medications often contain active ingredients such as antihistamines, decongestants, antitussives, expectorants, and analgesics-antipyretics. The combination of multiple ingredients in these products significantly increases the risk of adverse effects and unintentional overdoses. Several case studies have reported significant toxicity and even fatalities associated with the use of these medications in children. This review underscores the critical importance of clinical toxicology in evaluating the safety and toxicity profile of OTC medications employed for treating CCS in pediatric patients. The findings highlight the significance of informed clinical practice and public health policies to ensure the well-being of children using OTC cough and cold medications.

Chlorpheniramine, an Old Drug with New Potential Clinical Applications: A Comprehensive Review of the Literature

Chlorpheniramine Maleate (CPM), also known as chlorphenamine, is a potent alkylamine first-generation H1 antihistamine that has been used since the 1950s. CPM is a widely popular drug commonly used to treat allergic conditions, given its antihistamine properties. Although mainly used in over-the-counter treatment for cough and colds, various studies discuss a wide range of CPM's clinical uses, such as treating asthma, plasma cell gingivitis, chronic urticaria, and depression, among others. This antihistamine is usually taken orally; however, intravenous, intramuscular, and subcutaneous routes have been documented. Intranasal routes of this drug have recently been explored, especially due to its antiviral properties against severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Accordingly, given CPM's extensive medical and safety profile, the present review explores this versatile drug's current and potential clinical applications. Although it is widely used mainly for treating common colds and aforementioned allergic conditions, CPM can be used for other clinical indications. The repurposing of CPM for other clinical indications, such as COVID-19, needs to be further explored through more extensive studies.

Cough medicines for children- time for a reality check

Cough medicines have been in use for over a century to treat the common and troublesome, but often helpful, symptoms of cough in children. They contain various combinations of "anti-tussive" drugs including opioids, antihistamines, herbal preparations, mucolytics, decongestants and expectorants. Whilst theoretically attractive for symptom relief when children are suffering, as time has passed these popular over the counter medicines have been shown to lack efficacy, delay more serious underlying diagnoses, and can cause complications and sometimes death. This has resulted in clinician concerns, a citizen petition to the American Food and Drug Association in 2007, some self-regulation from manufacturers and escalating restrictions on their use from regulatory agencies across the world over the last twenty years. This article will review the protective role of cough, juxtapose the conflicting treatment goals of suppressing a dry cough and promoting expectoration for a wet cough, consider the evidence basis for prescribing cough medicines in comparison to other more specific treatments such as for asthma [beta agonists] or infection [antibiotics], regulatory interventions, and conclude with the view that over counter cough medicines should not be used in children, especially young children.

Infant dextromethorphan and dextrorphan exposure via breast milk from mothers who are CYP2D6 extensive metabolizers

The risk of infant exposure to dextromethorphan (DM) and its active metabolite, dextrorphan (DX), through breast milk has not been evaluated. In this study, bound and unbound DM and DX concentrations in breast milk and plasma at 2 h post-dose were measured in 20 lactating women (n = 20) following a single 30 mg oral dose of DM. The DM and DX concentrations in breast milk were positively correlated with their respective plasma concentrations. The breast milk-to-plasma (M/P) ratios of 1.0 and 1.6 and the unbound M/P ratios of 1.1 and 2.0 for DM and DX, respectively, suggested that DM and DX are extensively distributed into breast milk. The infant exposure following a single dose of 30 mg DM was estimated using the breast milk concentrations to be 0.33 ± 0.32 μg/kg/day and 1.8 ± 1.0 μg/kg/day for DM and DX, respectively. The steady-state infant exposure was estimated using the M/P ratios and previously reported AUC of DM and DX following repeated dosing of DM 60 mg orally twice daily to be 0.64 ± 0.22 μg/kg/day and 1.23 ± 0.38 μg/kg/day, respectively. Based on these estimated infant doses, the relative infant doses (RIDs) were estimated to be <1%, suggesting the infant is only exposed to a minor fraction of adult dose through breast milk; however, one nursing infant developed an erythematous rash during this study which warrants additional research to fully elucidate the risks of infant exposure to DM and DX through breast milk. This article is protected by copyright. All rights reserved.

Complementary And Alternative Medicine Practitioner's Management Of Acute Respiratory Tract Infections In Children - A Qualitative Descriptive Study

BACKGROUND

Acute respiratory tract infection (ARTI) is one of the most prevalent types of infection among children and a common reason for hospital admission. Although parents frequently consult complementary and alternative medicine (CAM) practitioners to assist with the management of childhood ARTI, little is known about the treatments that CAM practitioners recommend and why. The aim of this research was to understand what CAM practitioners typically prescribe for the management of childhood ARTI and how practitioners formulate decisions regarding the management of this condition.

METHOD

The research was guided by a qualitative descriptive framework. CAM practitioners across Greater Melbourne (Victoria, Australia) who had treated children aged 0-12 years with ARTI in the past 12 months were eligible to participate. Data were captured using semi-structured interviews, which were audio-recorded and transcribed verbatim. Multiple strategies to improve trustworthiness were implemented (e.g., triangulation of data). Data were analysed using inductive content analysis.

RESULTS

Twenty-four CAM practitioners from ten different disciplines participated in the interviews. Most participants were female (75%), and more than half (54%) were practicing naturopaths. The treatments most commonly recommended were lifestyle modification (95%), nutrition/diet-based treatments (91%), and vitamin/mineral supplementation (87%). Practitioners' decision-making process was underpinned by four key concepts namely: the approach to management, individualisation, do no harm, and collaborative practice. Individualisation and the safety of the child are cornerstones of treatment in the practitioner's decision-making process.

CONCLUSION

This research sheds light on commonly used CAM interventions, many of which build on easily accessible and readily available treatments (such as soups) and are aligned with mainstream recommendations (such as rest). Practitioners' decision-making process too aligns well with mainstream health care where the focus is on safety and informed by a biopsychosocial-cultural approach.

The effects of antihistamines on the semiology of febrile seizures

OBJECTIVE

The aim of this study was to clarify the effects of antihistamines on the semiology of febrile seizures.

METHODS

The manifestations of febrile seizures were recorded using a structured questionnaire immediately after patients arrived at the hospital. We focused on events at seizure commencement, including changes in behavior and facial expression, and ocular and oral symptoms. The presence or absence of focal and limbic features was determined for each patient. Drugs taken within 6 h prior to seizure were noted. Seizure manifestations were compared between children who did not take antihistamines and those who took antihistamines.

RESULTS

Seizures lasting ≥5 min were relatively more frequent in children who did not take antihistamines, although the difference was not statistically significant. One or more focal features were present in 60 of 78 children with no antihistamines and 17 of 23 children with antihistamines. One or more limbic features were present in 32 of 78 children with no antihistamines and 9 of 23 children with antihistamines. No significant difference in the numbers of focal or limbic features was apparent between children who did not take antihistamines and those who took antihistamines.

CONCLUSION

Antihistamines did not significantly affect the semiology of febrile seizures.

A Review of the Ingredients Contained in Over the Counter (OTC) Cough Syrup Formulations in Kenya. Are They Harmful to Infants?

Background

Cough syrups are widely used in the developing world, but safety of their use in infants and children less than two years has not been well documented. Some syrups contain multiple combinations of such drugs as promethazine, diphenhydramine and ephedrine; which are individually now contraindicated in children less than two years. Despite this, the syrups are available as over the counter drugs and may be dispensed to mothers who are unaware of the potentially hazardous effects to their infants. A descriptive cross-sectional study was used to investigate suitability of cough syrups sold within Eldoret municipality for use in children less than two years of age based on their formulations and available literature.

Methods

Two semi-structured questionnaires were administered to pharmacy attendants and mothers attending sick child clinic at a referral hospital to establish whether cough syrups containing more than one active ingredient of compounds, now contraindicated in children are administered to infants, and awareness of potential serious adverse effects. Data from labeled contents of cough syrups from retail pharmacies was recorded and corroborated with information from literature to determine those deemed to contain the ingredients. The second questionnaire was administered to mothers with children less than two years to ascertain whether they had used the identified syrups. A total of 260 mothers and 55 pharmacy attendants were interviewed.

Results

There was widespread use of the syrups in children, including infants, with 192 (74%) of the respondents having used identified syrups and over 90% of these on children less than 2 years including those less than three months.146 (76%) mothers had administered the syrup at double the recommended dose.

Conclusion

The regulatory authorities should make concerted efforts to discourage use of cough syrups containing ingredients that pose adverse events to infants, including campaigns to educate pharmacy workers and mothers.

The Effect of Viola odorata Flower Syrup on the Cough of Children With Asthma: A Double-Blind, Randomized Controlled Trial

This study aimed to investigate the effect of violet syrup on cough alleviation in children with intermittent asthma. In a parallel, double-blind, randomized controlled trial, 182 children aged 2 to 12 years with intermittent asthma were randomly assigned 1:1 to receive violet syrup or placebo along with the common standard treatments in both groups (short-acting β-agonist). Both groups were evaluated in terms of the duration until cough suppression was achieved. No significant difference was observed in basic characteristics. The duration lasting to yield more than 50% cough reduction and 100% cough suppression was significantly less in the violet syrup group compared to placebo (P = .001, P < .001, respectively). There was no significant difference in therapeutic effects between boys and girls. There was a significant inverse correlation between the age of children and rate of cough alleviation and suppression by violet syrup. This study showed that the adjuvant use of violet syrup with short-acting β-agonist can enhance the cough suppression in children with intermittent asthma.

Prescribing practices of physicians at different health care institutions

OBJECTIVE

Irrational pharmacotherapy is a widespread health care problem, and knowing the prescription practices of physicians at an institutional level can present solutions. This study aimed to investigate whether physicians' prescribing patterns showed differences at the level of the health care institution.

MATERIALS AND METHODS

Photocopies of 3201 prescriptions written at primary health care centers (PHCs), public hospitals, private hospitals, and university hospitals (UHs) were collected from 10 provinces in Turkey. The prescriptions were evaluated according to prescribing indicators, and the details of drug utilization were compared for different health care institutions.

RESULTS

The average number of medicines per prescription was 2.83, and the highest average was noted in PHCs (2.96). The average cost per prescription was US $51.57, and the highest average cost was found in UHs (US $166.10). The most frequently prescribed drug group was different among health care institutions. With the exception of UHs, the "cold-cough medicines" were the most frequently prescribed medicines at all of the institutions. Thirty-nine percent of the prescriptions included antibiotics.

CONCLUSION

Despite the similarities between the distributions of diagnoses on prescriptions by health care institutions, the contents of the prescriptions showed differences. The high levels of prescriptions for "cold-cough medicines," whose use is widely debated, and the widespread tendency of physicians to prescribe antibiotics suggest that there is a growing need for disseminating the principles of rational pharmacotherapy. Furthermore, institutional differences must be considered when conducting rational pharmacotherapy programs.

Lessons learned from a double-blind randomised placebo-controlled study with a iota-carrageenan nasal spray as medical device in children with acute symptoms of common cold

Background

Common cold is caused by a variety of respiratory viruses. The prevalence in children is high, and it potentially contributes to significant morbidity. Iota-carragenan, a polymer derived from red seaweed, has reduced viral load in nasal secretions and alleviated symptoms in adults with common cold.

Methods

We have assessed the antiviral and therapeutic activity of a nasal spray containing iota-carrageenan in children with acute symptoms of common cold. A cohort of 153 children between 1–18 years (mean age 5 years), displaying acute symptoms of common cold were randomly assigned to treatment with a nasal spray containing iota-carrageenan (0.12%) as verum or 0.9% sodium chloride solution as placebo for seven days. Symptoms of common cold were recorded and the viral load of respiratory viruses in nasal secretions was determined at two consecutive visits.

Results

The results of the present study showed no significant difference between the iota carrageenan and the placebo group on the mean of TSS between study days 2–7. Secondary endpoints, such as reduced time to clearance of disease (7.6 vs 9.4 days; p = 0.038), reduction of viral load (p = 0.026), and lower incidence of secondary infections with other respiratory viruses (p = 0.046) indicated beneficial effects of iota-carrageenan in this population. The treatment was safe and well tolerated, with less side effects observed in the verum group compared to placebo.

Conclusion

In this study iota-carrageenan did not alleviate symptoms in children with acute symptoms of common cold, but significantly reduced viral load in nasal secretions that may have important implications for future studies.

Trial registration

ISRCTN52519535, http://www.controlled-trials.com/ISRCTN52519535/

Safety considerations in the management of allergic diseases: focus on antihistamines

OBJECTIVE

To conduct a systematic review of evidence supporting the safety profiles of frequently used oral H(1)-antihistamines (AHs) for the treatment of patients with histamine-release related allergic diseases, e.g. allergic rhinitis and urticaria, and to compare them to the safety profiles of other medications, mostly topical corticosteroids and leukotriene antagonists (LTRA).

RESEARCH DESIGN AND METHODS

Systematic search of the published literature (PubMed) and of the regulatory authorities databases (EMA and FDA) for oral AHs.

RESULTS

Similarly to histamine, antihistamines (AHs) have organ-specific efficacy and adverse effects. The peripheral H(1)-receptor (PrH1R) stimulation leads to allergic symptoms while the brain H(1)-receptor (BrH1R) blockade leads to somnolence, fatigue, increased appetite, decreased cognitive functions (impaired memory and learning), seizures, aggressive behaviour, etc. First-generation oral AHs (FGAHs) inhibit the effects of histamine not only peripherally but also in the brain, and additionally have potent antimuscarinic, anti-α-adrenergic and antiserotonin effects leading to symptoms such as visual disturbances (mydriasis, photophobia, and diplopia), dry mouth, tachycardia, constipation, urinary retention, agitation, and confusion. The somnolence caused by FGAHs interferes with the natural circadian sleep-wake cycle and therefore FGAHs are not suitable to be used as sleeping pills. Second-generation oral AHs (SGAHs) have proven better safety and tolerability profiles, much lower proportional impairment ratios, with at least similar if not better efficacy, than their predecessors. Only SGAHs, and especially those with a proven long-term (e.g., ≥12 months) clinical safety, should be prescribed for young children. Evidence exist that intranasally applied medications, like intranasal antihistamines, have the potential to reach the brain and cause somnolence.

CONCLUSIONS

Second-generation oral antihistamines are the preferred first-line treatment option for allergic rhinitis and urticaria. Patients taking SGAHs report relatively little and mild adverse events even after long-term continuous treatments. An antihistamine should ideally possess high selectivity for the H(1)-receptor, high PrH1R occupancy and low to no BrH1R occupancy.

Antitussive effects of memantine in guinea pigs

BACKGROUND

The treatment of cough is a significant clinical unmet need because there is little evidence that current therapies are effective. Based on evidence supporting a role for N-methyl D-aspartate receptors (NMDARs) in cough, we hypothesized that memantine, a low-affinity, uncompetitive NMDAR channel blocker in routine use for the treatment of Alzheimer disease, could be an effective, well-tolerated, antitussive therapy. The aim of this study was to establish preclinical evidence that memantine has antitussive effects.

METHODS

We studied the influence of memantine on experimentally induced coughing in response to citric acid and bradykinin inhalation in guinea pigs. We also compared the potency and efficacy of memantine as an antitussive to other NMDAR antagonists, dextromethorphan and ketamine, and to the γ-aminobutyric acid class B receptor agonist baclofen.

RESULTS

Compared with control subjects, 10 mg/kg memantine significantly reduced the cumulative number of coughs evoked by both citric acid (median, 24.0 [interquartile range (IQR), 13.0-25.5] vs 1.5 [IQR, 0.3-10.3] coughs; P = .012) and bradykinin aerosols (median, 16.0 [IQR, 9.5-18.5] vs 0.0 [IQR, 0-0.75] coughs; P = .002). Memantine 10 mg/kg produced a similar reduction in the cumulative number of coughs to baclofen 3 mg/kg and demonstrated comparatively greater cough suppression than 30 mg/kg dextromethorphan or 30 mg/kg ketamine. This dose of memantine produced no sedative or respiratory depressive effects.

CONCLUSIONS

This study illustrates that memantine has marked antitussive effects in guinea pigs, most likely mediated through NMDAR channel blockade. Memantine, therefore, has the potential to be a safe, effective, and well-tolerated antitussive agent.