Recommendations for the Use of OTC Cough and Cold Medications in Children

Ann McMahon Wicker, PharmD, BCPS; Brice A. Labruzzo, PharmD


US Pharmacist. 2009;34(3):33-36. 

In This Article


Codeine, although not available OTC in all states, is the gold-standard antitussive. Nonprescription antitussives that are available OTC to treat cough are dextromethorphan and diphenhydramine.[10] Codeine produces cough suppression by acting centrally on the cough center located in the medulla portion of the brainstem. When used at antitussive doses, codeine should not exhibit addictive properties.[10] Dextromethorphan, the D-isomer of codeine, exerts its pharmacologic action in the same way as codeine; however, it lacks analgesic and addictive properties when used at recommended doses.[4,5] In children, the recommended dose of both dextromethorphan and codeine is 1 mg/kg/day divided into four doses, with an MDD of 30 mg for children aged 2 to 5 years.[2,11] Recommended dosing for diphenhydramine, a first-generation antihistamine, in children aged less than 6 years is 5 mg/kg/day divided every six hours, with an MDD of 300 mg.[2]

Side effects of codeine include lightheadedness, dizziness, sedation, GI effects, and sweating. The most common effects resulting from an overdose are respiratory depression and a decreased level of alertness or consciousness. It has been reported that codeine is unlikely to produce significant side effects in children given less than 2 mg/kg; however, somnolence, ataxia, miosis, vomiting, rash, facial swelling, and itching have been reported in children receiving codeine doses of 3 to 5 mg/kg/day. Side effects of dextromethorphan include drowsiness, dizziness, nausea, GI upset, and abdominal discomfort.[4] Dextromethorphan may cause behavioral disturbances and respiratory depression when overdosage occurs.

Insufficient evidence exists to support the use of codeine or dextromethorphan for antitussive purposes in the pediatric population.[11] Pharmacists should counsel parents about the lack of data supporting the use of these drugs for antitussive purposes as well as the potential risks associated with their use. Additionally, evidence suggests that second-generation nonsedating antihistamines such as loratadine are ineffective for lessening cough associated with the common cold, and therefore should not be used.[12]