OTC spotlight: cough and cold medicines for children

Why this matters

Coughs and colds are among the most common reasons a parent or carer comes to the counter, especially from autumn onwards. They usually get better on their own. That is exactly why the rules on children's cough and cold medicines are cautious: when an illness clears up by itself, a medicine has to be clearly worth any risk it carries.

The MHRA reviewed these medicines with advice from the Commission on Human Medicines. It found no robust evidence that they work in children, and there had been reports of harm. The result was a set of age limits that every counter assistant needs to know. The first question in any sale is always the same: who is it for, and how old are they?

The age limits

• Under 6: over the counter cough and cold medicines containing the ingredients listed below should not be used. For this age group the balance of benefit and risk was not shown to be favourable.
• 6 to 12: these medicines can still be supplied, but only from a pharmacy, where advice can be given. They are meant as an extra to basic care, not a replacement for it.
• Liquid products containing these ingredients are supplied in child resistant containers, to help prevent accidental overdose.
• Codeine is a separate matter. It must not be used for cough and cold in children under 12, and it is not recommended for 12 to 18 year olds who have breathing problems. Refer any request involving codeine and a young person to the pharmacist.

Always read the age on the pack in front of you. Products with similar names can have different ingredients and different age limits, and the pack and leaflet are the final word for that product.

Which ingredients are covered

You do not need to memorise every name, but you should recognise the four groups:

• Cough suppressants: dextromethorphan and pholcodine
• Expectorants: guaifenesin and ipecacuanha
• Nasal decongestants: ephedrine, oxymetazoline, phenylephrine, pseudoephedrine and xylometazoline
• Antihistamines: brompheniramine, chlorphenamine, diphenhydramine, doxylamine, promethazine and triprolidine

Some of these are no longer found in products on your shelves, but the list is still useful when a parent brings in an old bottle from the cupboard at home and asks whether they can use it.

What you can suggest instead

NHS advice for coughs and colds centres on simple care, and most of it is something you can explain with confidence:

• Rest and plenty of fluids.
• Paracetamol or ibuprofen for aches or a high temperature, in a children's product that suits the child's age. Follow your sales protocol and check the pack.
• A warm lemon and honey drink for older children. Honey must not be given to babies under 12 months, and hot drinks should not be given to small children.
• Steam should not be inhaled from a bowl of hot water by children, because of the risk of scalding.
• Aspirin must not be given to children under 16.

Remind parents that many cold remedies for older children and adults contain paracetamol. Giving one alongside a separate paracetamol product can mean the child gets more than they should. It also helps to say that a cold can last longer in young children than in adults, so slow progress is not unusual.

WWHAM in practice

Who is it for? Ask the child's age every time, even if the parent asks for a product by name. What are the symptoms: a cough, a blocked nose, a temperature, or all three? How long has it been going on? Action already taken: what have they given so far, and when was the last dose? Medicines: does the child take anything else, and do they have any long-term condition?

Parents are often tired and worried, and being told a medicine is not suitable can feel like being turned away. Explain the reason briefly and kindly, then move straight to what they can do. A parent who leaves with clear advice has been helped, even without a bottle of cough medicine.

When to refer to the pharmacist

• Any request for a cough and cold medicine for a child under 6, and for babies in particular
• A child aged 6 to 12, if your protocol asks for the pharmacist to be involved in these sales
• Difficulty breathing, shortness of breath or chest pain: tell the pharmacist straight away
• A high temperature lasting more than 3 days, or a very high temperature
• A cough lasting more than 3 weeks, or cold symptoms not improving after 10 days
• Symptoms that are getting worse, or a child who seems very unwell
• A child with a long-term condition or a weakened immune system
• Any request for a codeine product for someone under 18
• A parent who is simply worried. The NHS lists concern about a child's symptoms as a reason to seek advice, so it is a good enough reason to refer.

PPets learning connection

This spotlight supports the OTC consultation, WWHAM and red flags learning in the Level 2 Certificate. Our free OTC red flags guide is a useful counter reference.

Record this as CPD

Registered pharmacy technicians can use this article towards GPhC revalidation, as an unplanned CPD entry or as the starting point for a reflective account. Pharmacy assistants and trainees can use it as evidence of reflective practice. Note down three things:

1. What you learned from this article
2. How you have applied it, or will apply it, in your own role
3. The benefit to the people who use your pharmacy's services

Sources and further reading

• MHRA Drug Safety Update: over-the-counter cough and cold medicines for children
• MHRA Drug Safety Update: codeine for cough and cold, restricted use in children
• NHS: cough
• NHS: common cold

Related from PPets

• OTC consultation training
• Community pharmacy red flags
• WWHAM training

This article is for general educational purposes only. It is not legal advice, professional regulatory advice or clinical advice about an individual patient. Always follow your pharmacy's SOPs and check current official guidance and product information.

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