February 06, 2012

Like most of you, I am certain, it seems as if almost every patient I have seen this month has complained of a cough (or, rather, their parents have complained of their children’s coughs).

We are well into respiratory virus season so this isn’t at all unexpected and is rarely concerning (although a detailed history and physical should always be completed to look for something more serious). As I have been making recommendations for supportive care, I have been thinking about how parents respond to this advice, and what the evidence is behind it. In my experience, a child’s cough is scary to parents and disrupts their sleep, so they really want to do something about it. However, that "something" doesn’t have to be medication.

First and foremost, I reassure parents that a cough can be expected with many viral infections, and that it may last a long time – up to a month (though it should be getting better). Even more complicating, many children get multiple upper respiratory infections, causing a greater prolongation of symptoms. Taking a few minutes to ask detailed questions about the history of the cough, when the cough occurs, how it sounds, and what some of the associated symptoms are assures parents (and myself) that I am taking their concerns seriously. A little bit of empathy also goes a long way. It is no fun for parents to see their children feeling crummy, and to stay up most of the night listening to their coughing.

This is well known by now, but over-the-counter cough and cold medicines have not proved effective in treating children’s cough, and they can have significant side effects. Many parents have heard this as well, so I am asked about this less frequently, but I am always sure to reinforce the message that these are not helpful medications. "Well, what can I give him?" is always the next question. The implied message is that I must give them other ideas.

Here is where it gets tricky. There is little evidence to back the supportive treatments we all often recommend. But frequently, these treatments carry little risk.

Parents often ask about humidified air. A 2009 Cochrane review of heated humidified air in the symptomatic treatment of colds showed fairly mixed results (Cochrane Database Syst. Rev. 2009 [doi:10.1002/14651858.CD001728.pub3]). Only six studies were eligible for inclusion, with some studies showing minor evidence of symptom improvement, and no study showing very clear benefits. Some minor side effects related to irritation from the steam were described. Burns from the hot steam have also been described elsewhere. My practice is to actually recommend cool mist humidifiers if the family already owns one. I definitely don’t recommend buying one. From my perspective, there are minimal side effects from the cool mist, and therefore, it is a reasonable thing to try. The one caveat is that the water tanks can develop mold growth quite quickly, and therefore should be diligently cleaned each day according to the manufacturer’s instructions.

My other favorite recommendation is honey (though I know that all don’t agree with me). There is a single study suggesting there may be some benefit (though not enough to really feel certain), and for children over the age of 1 year, it is a very safe treatment. It is easily available, many families already have some in their house, and grandmother almost always approves. I made that recommendation to a family today, and the parents smiled, laughed, and gave each other a high five. They said, "That is what great-grandma has been saying, and we wanted to try it, but we weren’t sure it was okay."

Throat lozenges in older children are another option. There is really no evidence to support this recommendation, but it is a generally safe alternative (except for the risk of choking, so it’s for older children only). Some critics say that these work by placebo effect only, but in this situation, I think that is okay!

In the end, I find that a few reassuring words, careful instructions on signs of worsening, and a promise to parents that they can call me if they have any questions are the most effective treatment of all. And, of course, lots of rest and fluids, as Grandma recommends.

Dr. Beers is assistant professor of pediatrics at Children’s National Medical Center in Washington. She is a member of the Pediatric News editorial advisory board, a member of the American Academy of Pediatrics Committee on Residency Scholarships, and president-elect of the District of Columbia chapter of the American Academy of Pediatrics. She said she had no relevant financial disclosures. 

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