As we start to ease (sneeze?) into another cold and flu season we also start to deal with requests for cold and flu medications. In the pediatric realm the recommendations have been clear for many years – cold and cough medications are not only ineffective but potentially dangerous, especially for the youngest patients.
As far back as 1997 the AAP released a policy statement recommending against use of cold and cough medicines for children. This policy was reinforced in 2006 which then culminated in the voluntary removal of all products for children under 2 from US pharmacies. The AAP went even further: recommending no use of cold medicines for children under 6.
In addition, many children (and adults) are prescribed codeine cough medicines to help with nighttime cough. However, just as with the cold medications, for children codeine has never been shown to be any better than placebo and probably less effective than honey. (See previous blog post – Honey for pediatric cough)
However, many physicians have continued to prescribe these medications even in the face of all these recommendations. One recent study looked at a 10+ year period of ED records – about half before the 2006 events and half after and found only a slight decrease in the use of codeine overall in children and no difference in codeine prescribed for cough.
While codeine can also be used for pain for acute injuries there are a number of children that are poor metabolizers for converting codeine to morphine in vitro thus making it essentially useless as a pain medication. On the other hand, some children (anywhere from 2-40% depending on ethnic background) are ultra-fast metabolizers of codeine which means they receive a morphine dose 5-30x more than expected which can lead to severe side effects such as respiratory depression and death.
Because of the lack of efficacy and potential for significant side effects documented in numerous studies PHC is joining the trend by limiting codeine products in our formulary for members less than 18. For post-surgical pain control hydrocodone/acetaminophen elixir (2.5/167 mg elixir) will still be formulary with restrictions for volume.
For pediatric cough the old stand-bys still work: moisture (vaporizer), vapor rub, warm drinks and honey.
Jeff Ribordy, MD
Regional Medical Director