BNF for Children 2011-2012

BNFC 2011–2012 3.9 Cough preparations 1673.9 Cough preparations3.9.1 Cough suppressants3.9.2 Expectorant and demulcent coughpreparations3.9.1 Cough suppressantsCough may be a symptom of an underlying disordersuch as asthma (section 3.1), gastro-oesophageal refluxdisease (section 1.1), or rhinitis (section 12.2.1), whichshould be addressed before prescribing cough suppressants.Cough may be associated with smoking or environmentalpollutants. Cough can also result frombronchiectasis including that associated with cysticfibrosis; cough can also have a significant habit component.There is little evidence of any significant benefitfrom the use of cough suppressants in children withacute cough in ambulatory settings. Cough suppressantsmay cause sputum retention and this can be harmful inchildren with bronchiectasis.The use of cough suppressants containing pholcodineor similar opioid analgesics is not generally recommendedin children and should be avoided in childrenunder 6 years; the use of over-the-counter codeinecontainingliquids should be avoided in children under18 years, see MHRA/CHM advice below.Sedating antihistamines (section 3.4.1) are used as thecough suppressant component of many compoundcough preparations on sale to the public; all tend tocause drowsiness which may reflect their main mode ofaction.MHRA/CHM advice (March 2008 and February2009)Children under 6 years should not be given over-thecountercough and cold medicines containing thefollowing ingredients:. brompheniramine, chlorphenamine, diphenhydramine,doxylamine, promethazine, or triprolidine(antihistamines);. dextromethorphan or pholcodine (cough suppressants);. guaifenesin or ipecacuanha (expectorants);. phenylephrine, pseudoephedrine, ephedrine,oxymetazoline, or xylometazoline (decongestants).Over-the-counter cough and cold medicines can beconsidered for children aged 6–12 years after basicprinciples of best care have been tried, but treatmentshould be restricted to five days or less. Childrenshould not be given more than 1 cough or coldpreparation at a time because different brands maycontain the same active ingredient; care should betaken to give the correct dose.MHRA/CHM advice (October 2010) Over-thecountercodeine-containing liquid medicinesfor childrenChildren under 18 years should not use codeinecontainingover-the-counter liquid medicines forcough suppressionPHOLCODINECautions asthma; chronic, persistent, or productivecough; interactions: Appendix 1 (pholcodine)Contra-indications chronic bronchitis, bronchiectasis,bronchiolitis, children at risk of respiratory failureHepatic impairment avoidRenal impairment use with caution; avoid in severeimpairmentPregnancy manufacturer advises avoid unless potentialbenefit outweighs riskBreast-feeding manufacturer advises avoid unlesspotential benefit outweighs risk—no informationavailableSide-effects nausea, vomiting, constipation, sputumretention, drowsiness, dizziness, excitation, confusion,rashIndication and doseDry cough (but not generally recommended forchildren, see notes above). By mouthChild 6–12 years 2–5 mg 3–4 times dailyChild 12–18 years 5–10 mg 3–4 times dailyPholcodine Linctus, BPLinctus (= oral solution), pholcodine 5 mg/5 mL in asuitable flavoured vehicle, containing citric acidmonohydrate 1%. Net price 100 mL = 31pBrands include Pavacol-D c (sugar-free), Galenphol c (sugar-free)Pholcodine Linctus, Strong, BPLinctus (= oral solution), pholcodine 10 mg/5 mL in asuitable flavoured vehicle, containing citric acidmonohydrate 2%. Net price 100 mL = 44pBrands include Galenphol cGalenphol c (Thornton & Ross)Paediatric linctus (= oral solution), orange, sugarfree,pholcodine 2 mg/5 mL. Net price 90-mL pack =£1.203.9.2 Expectorant anddemulcent coughpreparationsSimple linctus and other demulcent cough preparationscontaining soothing substances, such as syrup or glycerol,may temporarily relieve a dry irritating cough.These preparations have the advantage of being harmlessand inexpensive and sugar-free versions are available.Expectorants are claimed to promote expulsion ofbronchial secretions but there is no evidence that anydrug can specifically facilitate expectoration.Compound cough preparations for children are onsale to the public but should not be used in childrenunder 6 years; the rationale for some is dubious. Careshould be taken to give the correct dose and to not usemore than one preparation at a time, see MHRA/CHMadvice above.3 Respiratory system