A child develops a persistent cough, sleep is disrupted and parents understandably want quick relief. In that moment, a familiar cough syrup can seem like the easiest answer. But paediatricians say the label deserves as much attention as the brand name. Many cough and cold preparations contain more than one active ingredient, and the same ingredient may also be present in another medicine a child is taking. This can increase the risk of accidental overdosing.
The US Food and Drug Administration (FDA), for instance, warns that children can be harmed when medicines are given too frequently, in excessive amounts or when two products containing the same ingredient are combined. More importantly, cough and cold medicines do not necessarily make a routine viral cough disappear faster. The World Health Organization has noted that most childhood respiratory infections are self-limiting and that medicines used for viral common colds provide few measurable benefits.
In India, the latest move involves fixed-dose combination (FDC) medicines containing chlorpheniramine maleate and phenylephrine hydrochloride, which the Centre has now restricted for children below four years of age. So, before giving a child a cough syrup, parents should check the active ingredients, age recommendations and dose, and ideally seek advice from a paediatrician or pharmacist.
Dr Rohan Grotra, Consultant - Pediatric Gastroenterology and Hepatology at Madhukar Rainbow Children's Hospital, said the issue is not about frightening parents away from treating a child's cough, but about making an informed choice. Dr Aditi Sachdeva, Consultant - Paediatrics & Neonatology at CK Birla Hospital, Delhi, similarly stressed the importance of reading the ingredients rather than relying only on the brand name.
1. Dextromethorphan
Dextromethorphan (DXM) is a cough suppressant that acts on the brain's cough centre. While it is present in many formulations, its usefulness in children with an ordinary viral cough is not straightforward.
A randomised study published in Pediatrics involving 100 children found that neither dextromethorphan nor diphenhydramine was superior to placebo for relieving night-time cough or improving sleep. More recent research has found some benefit from dextromethorphan in children aged 6-11, showing why its use should be based on the child's age, symptoms and medical advice rather than simply the presence of a cough.
Parents should therefore never assume that a higher dose will provide better relief.
2. Sedating antihistamines: Promethazine and Diphenhydramine
Antihistamines such as promethazine and diphenhydramine may be included in cough and cold formulations, partly because they can cause drowsiness. But sedation is not the same as effective cough treatment. Diphenhydramine caused more drowsiness in the Pediatrics study without providing better night-time cough relief than placebo.
The risks are particularly important in very young children. The FDA warns against cough and cold products containing antihistamines or decongestants in children under two because serious, potentially life-threatening effects have been reported. Some countries have adopted broader restrictions for young children.
3. Alcohol (Ethanol)
Some liquid medicines use ethanol as an excipient or solvent. It is therefore worth checking the label, particularly when a child is receiving several medicines.
The European Medicines Agency notes that ethanol-containing medicines can have effects in younger children and that co-administration of medicines containing ethanol can contribute to accumulation, particularly in young children with immature metabolic capacity. This does not mean that every medicine containing a small amount of ethanol is dangerous. Rather, the amount and the child's age and weight matter-another reason not to self-medicate.
4. Paracetamol or Ibuprofen
Some combination cough and cold medicines also contain a fever or pain medicine such as paracetamol (acetaminophen) or, in some formulations, ibuprofen. The potential problem is duplication: a parent may give a combination cough syrup and then administer a separate fever medicine without realising that the same active ingredient has already been given. The FDA specifically warns about this form of accidental overdose and recommends checking active ingredients before combining medicines.
5. Codeine
Codeine deserves particular caution. It is an opioid that the body converts into morphine, but people metabolise it at different rates. The European Medicines Agency concluded that codeine-containing medicines for cough and cold should not be used in children under 12 because conversion to morphine can be unpredictable and potentially cause serious breathing problems. Evidence supporting codeine's effectiveness for children's cough is also limited.
What Parents Should Do
As Dr Grotra put it, the safest medicine is not necessarily the strongest one, it is the one given correctly, to the right child, at the right dose.
For a young child, particularly an infant or toddler, parents should seek medical advice before giving a cough or cold medicine. Simple supportive measures such as adequate fluids, saline nasal drops and appropriate humidification may be sufficient for many uncomplicated viral illnesses.
A cough is a symptom, not a diagnosis, and suppressing it is not always necessary. Before reaching for a cough syrup, parents should check the active ingredients, age restrictions, dosage and whether another medicine already contains the same ingredient. Most importantly, children's cough and cold medicines should be given only on appropriate medical advice, particularly in younger children.
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