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PROFESSIONAL DEVELOPMENT AND PRACTICE SUPPORT FOR THE SELF CARE PROGRAM
Childhood
cough and cold
V ol .15
NUMBER 4
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John Bell says
Contents
MAY 2014
V ol .15
NUMBER 4
Managing editor Andrew Daniels
Production coordinator Kylie Stewart
Contributor Sarah Curulli
Peer review Anna Ezzy
Layout Caroline Mackay
The common cold is a significant cause of
burden and distress.
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program, contact PSA at the address below.
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Views expressed by authors of articles in
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The information contained in this material is
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authoritative evidence. Any treatment
decisions based on this information should be
made in the context of the clinical circumstances
of each patient.
See page 4, Facts Behind the Fact Card: Childhood cough and cold
PHARMACIST CPD
4
Facts Behind the Fact Card: Childhood cough and cold
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inPHARMation May 2014 I © Pharmaceutical Society of Australia Ltd.
Health column
The right advice for today’s childhood cold
By Joey Calandra
For many Australian families the first sign of
winter approaching is often a child with a
fever, runny nose and a cough. Not surprising
as the common cold is the most frequently
reported short term illness reported in
children. Parents want to ensure that they
are caring for their families especially when
a child is unwell. Often this can mean using
what has worked in the past or believing that
antibiotics are the key to a cure.
Relying on what has worked in the past or
advice from friends is often not in the best
interests of the child’s health. When treating
a child, medicines can often be administered
by multiple caregivers, resulting in increasing
the chances of adverse effects and in some
instances unintentional overdose and
sudden infant death syndrome.
The Therapeutics Goods Administration
(TGA) reviewed the use of cough and cold
medicines in children because of the life
threatening situations that were arising.
The outcome was that cough and cold
medicines should not be given to children
under 6 years of age, and that cough and
cold medicines should only be given to
children aged 6–11 years on the advice of a
doctor, pharmacist or nurse practitioner.
Your local pharmacist can provide
reassurance and advice that although
parents know what’s best for their children,
there is now new evidence for the safest
way for treating children’s coughs and colds.
Sometimes this means simply ensuring that
a child has plenty to drink and gets enough
rest, as coughs and colds are self-limiting
and will usually get better by themselves.
effectively against bacteria when we
really need them. This is what is known as
antibiotic resistance – when antibiotics can
no longer cure bacterial infections – and has
been a concern for years and is considered
one of the world’s most critical public health
threats. In fact, in children, antibiotics are
the most common cause of emergency
department visits for adverse drug events.
However, on other occasions, your
pharmacist can advise that treating what
appears to be the symptoms of coughs and
colds in children with medicines, may delay
the diagnosis and treatment of more serious
conditions such as asthma, pneumonia and
meningococcal disease.
Your local community pharmacy is your
health destination and your Self Care
pharmacist can give you more information
about the best treatment for your child’s
cough and colds and provide support using
the Colds and flu and Children’s pain and
fever Self Care Fact Cards. For the nearest
location phone the Pharmaceutical Society
on 1300 369 772 or visit the website
www.psa.org.au and click on Self Care
Pharmacy Finder.
We all want the fastest and best way to
alleviate our colds, and that means we can
often get caught in the trap of thinking that
antibiotics are the answer. Antibiotics are
medicines used to treat infections caused by
bacteria. When it comes to a common cold,
the major cause is a viral infection, which
does not respond to antibiotic treatment.
If antibiotics are used too often for things
they can’t treat – like colds or other
viral infections – they can stop working
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inPHARMation May 2014 I © Pharmaceutical Society of Australia Ltd.
3
Childhood cough and cold
Pharmacist CPD
Module number 248
Childhood cough and cold
By Sarah Curulli
UP TO
John Bell
saysBehind the Fact Card
Facts
2
CPD CREDITS
GROUP 2
This education module is independently researched and compiled by PSA-commissioned authors and peer reviewed.
The common cold, although
a self-limiting condition, is a
significant cause of burden
and distress among Australian
children, and their families.1,2
Learning objectives
After reading this article, pharmacists
should be able to:
• Discuss the pathophysiology of
cough and cold
• Evaluate the use of medicines
available for cough and cold in
children
• Discuss recent changes to
Therapeutic Goods Administration
(TGA) recommendations on
childhood cough and cold medicines
• Describe best management and self
care options for childhood cough
and cold symptoms
• Interpret available evidence for natural
cough and cold remedies in children
• Recognise when to refer children
with cough and cold symptoms
• Provide appropriate counselling to
parents and caregivers regarding
cough and cold treatments and self
care measures.
Competency standards (2010): 1.2, 1.3,
2.1, 2.3, 6.1, 6.2, 6.3.
4
Given the restrictions around the use of cough and cold medicines, especially for children under the age of six,
it is essential to review alternative treatment options and self-care measures that can be recommended to
parents and caregivers.
Pathophysiology and
symptoms
A 2004 survey conducted by the Australian
Bureau of Statistics showed that the
common cold was the most frequently
reported short-term illness among children
in Australia.3 The major pathogenic cause
of the common cold has been identified as
viruses, such as, rhinovirus (more frequently
in adults than children), influenza virus,
adenovirus and coronavirus.1
The exact mechanism by which such
viruses cause cold symptoms is not well
defined, however, it is postulated that
bradykinin, lysyl-bradykinin and histamine
may be responsible for the associated nasal
congestion and rhinorrhoea.1 However,
the pathogenesis and immunological
response experienced during a cold will
vary depending on the specific viral cause –
for example, histamine mediated responses
do not occur in a rhinovirus infection.1
inPHARMation May 2014 I © Pharmaceutical Society of Australia Ltd.
Symptoms of the common cold include;
runny or blocked nose, fever, malaise, sore
throat, headache and most notably, cough.1
Cough is a protective mechanism that
aims to clear irritant material, such as
pathogens and foreign bodies, from the
airways.4 The cough reflex is triggered by
the stimulation of chemical or mechanical
irritant receptors in the upper airways and
lungs.4,5 This results in the transmission
of a message (via the vagal nerve) to the
medulla, leading to a cough.4 The common
cold (or an acute viral respiratory infection)
is the most frequent cause of an acute
cough of less than three weeks in duration
(See Table 1).4,6 However, there are other
potentially serious causes of a cough that
must also be considered when a child
presents with cough and cold symptoms.
Cough, in the absence of other symptoms
(such as rhinorrhoea, fever, and malaise)
may be related to conditions such as;
Childhood cough and cold
Pharmacist CPD
• pneumonia or bronchiolitis (with
associated respiratory distress)
• asthma (predominant nocturnal cough)
• pertussis (paroxysms of coughing)
• gastro-oesophageal reflex disease (GORD)
(more prevalent with feeding and usually
accompanied by reflux)
• suppurative lung disease (cough more
prevalent in the morning)
• foreign bodies (usually associated
with choking).2
Medicines for cough and
cold – Efficacy and safety in
children
To date, there is no known cure for a viral
respiratory infection such as the common
cold.1 Treatment is primarily focused on
symptomatic relief to ease discomfort and
stress for both children and their families.2
For the past 40 years, cough and cold
medicines have contained a combination
of drugs aimed at providing symptomatic
relief.6 There are several classes of
medicines which can be used to relieve
cough and cold symptoms; antihistamines,
antitussives, mucolytics, expectorants, and
decongestants. It is important to note that
there are specific precautions that must be
taken when recommending medication for
children aged two to 12 years (See 2012 TGA
recommendations).
Module number 248
as Histamine H1 receptor antagonists,
antihistamines may relieve histamine
induced allergic rhinitis-like symptoms such
as sneezing and rhinorrhea.1 Additionally,
some antihistamines have limited efficacy
as antitussive agents, primarily due to the
reduction in postnasal drip.1
First-generation antihistamines can
cause sedation (from slight drowsiness
to deep sleep), which is generally more
significant in children.1,6 Paradoxically,
when given in high doses, they may
cause stimulation and hyperactivity.6
First generation antihistamines can also
cause dizziness, irritability and toxic
effects such as hallucinations, convulsions
(may also precipitate seizures in children
with epilepsy), and cardio-toxicity
(QT prolongation).4,6,7 There is evidence of
specific case studies where children have
experienced severe toxicity, or even death,
following poisoning with an antihistamine,
namely diphenhydramine (the most
cardio‑toxic of the group).6 Additionally,
some antihistamines, such as promethazine,
are contraindicated in children under the
age of two, as they have been linked to
sudden infant death syndrome (SIDS).7
Overall, there is limited evidence that
antihistamines are beneficial for the
common cold.1 In addition, histamine levels
are not usually increased in the common
cold, and as such the use of antihistamines
has limited efficacy.1
First generation anti-histamines
Antitussives
Antihistamines such as diphenhydramine,
brompheniramine, chlorpheniramine,
doxylamine and promethazine may
provide symptomatic relief of cough and
cold symptoms.2,4 Due to their actions
Antitussives are commonly requested
in a pharmacy setting, as patients often
seek symptomatic relief from irritating
cough symptoms. Codeine (an opiate),
pholcodine (an opiate derivative) and
Facts Behind the Fact Card
Practice point 1
Summary of adverse effects of
OTC cough and cold medicines in
children1,2,4,6
• First-generation antihistamines:
Sedation, paradoxical hyperactivity,
dizziness, hallucinations, seizures,
cardio-toxicity.
• Antitussives: Dizziness, sedation,
nausea, allergic reactions, respiratory
depression with cyanosis (codeine)
• Mucolytics: No know adverse effects in
children.
• Expectorants: Nausea, vomiting,
gastrointestinal upset (high doses).
• Decongestants: Rebound congestion
(topical), sleep disturbances,
aggression, apnoea, seizures.
• Antihistamine-decongestant
combination products: Dystonic
reactions.
Note: When given in safe dosages these
medicines are unlikely to cause serious
adverse effects. However, overuse of
these medicines, or overdose can cause
serious harm.6,12
Table 1. Differential diagnosis; acute, persistent or chronic cough4,5
Acute cough
Persistent cough
Chronic cough (productive
and non-productive)
Duration
Three weeks or less
Several weeks to two
months
Greater than two months
Common causes
Upper or lower respiratory
infections
Post-infective (preceded by
acute respiratory infection)
Chronic bronchitis
Acute bronchitis
GORD
Bronchiectasis
Asthma exacerbation
Idiopathic
Croup
Upper airway cough
syndrome (post-nasal drip)
Sinusitis
Foreign bodies
Allergic rhinitis
Tuberculosis
Drug-induced
Lung cancer
Psychogenic (habitual)
Airway abnormalities
Foreign bodies
inPHARMation May 2014 I © Pharmaceutical Society of Australia Ltd.
5
John Bell
saysBehind the Fact Card
Facts
Practice point 2
Summary of TGA
recommendations12,15
• There have been no scheduling
changes to OTC cough and cold
medicines.
• Although there are no immediate
safety risks with the use of OTC
cough and cold medicines, there is
no evidence that these medicines are
beneficial or effective in children.
• There are some safety risks associated
with the use of these products for
children.
• OTC cough and cold medicines should
NOT be given to children aged six years
or younger.
• Children aged 6–11 years should ONLY
be given these products following
advice from a pharmacist, nurse
practitioner or doctor.
• All OTC cough and cold medicines must
be in child-resistant packaging, and
should have clear dosages for children
aged 6–11 years.
Childhood cough and cold
Pharmacist CPD
dextromethorphan (a narcotic derivative)
act centrally by suppressing the cough
centre in the medulla, most probably
by increasing the cough threshold.1,2
However there is limited evidence available
to support the efficacy of antitussive
medication;1,2,6 many studies conclude that
antitussives are no more effective than
placebo at treating cough symptoms.1,2,6,9
In particular, there is no evidence to
support the use of codeine, pholcodine
or dextromethorphan for acute cough
in children.4,6,9
Codeine can cause significant respiratory
depression and cyanosis; it is not
recommended in children due to the risk
of fatalities.6 Adverse effects of pholcodine
include; dizziness, sedation, nausea and
the potential for allergic reactions.2,4,6
Dextromethorphan has little sedative effect,
but has been associated with dizziness and
gastrointestinal upset.1 Due to the lack of
evidence of efficacy and the risk of side
effects, antitussive medications are not
routinely recommended for children.1,2
Mucolytics
Mucolytics , such as bromhexine, directly
loosen and thin bronchial secretions by
breaking sulfhydryl bonds.1,2 Although these
agents may bring about some subjective
improvement of symptoms, there is no
evidence that they improve pulmonary
function or treat acute respiratory
infections, such as the common cold.1
There is limited evidence available to
support the efficacy and use of bromhexine
in children.1 There is no evidence to
suggest that any adverse or toxic effects
are associated with the use of bromhexine
in children.6
Expectorants
Expectorants, such as guaiphenesin,
stimulate mucous production by bronchial
glands, leading to easier mucous expulsion
from the lungs through coughing or ciliary
transport.1,2 A recent Cochrane review (2012)
reported that the use of an expectorant may
be helpful in reducing cough intensity and
frequency.6 However, expectorants have
not been shown to improve the patients
overall condition, and no studies in children
have been published.1,8 In high doses,
expectorants may cause nausea, vomiting
and gastrointestinal upset.1,2,4,9
6
inPHARMation May 2014 I © Pharmaceutical Society of Australia Ltd.
Module number 248
Decongestants
Decongestants are typically
sympathomimetic agents that reduce
swelling of the nasal mucosa through
vasoconstriction (alpha/beta receptor
agonists).1,4 This leads to a reduction in nasal
congestion and an increase in sinus drainage.4
Decongestants can be administered topically
(such as oxymetazoline) or orally (such as
pseudoephedrine and phenylephrine).1
When used topically, for longer than two
to three days in succession, decongestants
can cause rebound congestion (rhinitis
medicamentosa).1 This is a concern for infants,
who are predominantly nasal breathers.
As such, the use of topical decongestants in
children is not routinely advised.1
There is limited evidence to support the
efficacy of oral decongestants in children.
Published randomised controlled trails show
conflicting results; some suggest that oral
decongestants may be no more effective
than placebo.1,10 Oral sympathomimetic
agents can cause a variety of adverse
effects, predominantly due to adrenergic
stimulation, such as; sleep disturbances,
aggression (specifically in young children),
seizures and apnoea.1,2,4 Due to limited
evidence of efficacy and the risk of adverse
effects, oral decongestants are also not
routinely recommended for use in children.1
Combination products
Antihistamine-decongestant combination
products are commonly used to relieve
cough and cold symptoms.6 There are
a variety of high-level studies which
conclude that the use of such a combination
provides no more benefit than placebo.10,11
Adverse effects, such as dystonic reactions,
have been reported following therapeutic
misadventure and poisoning with an
antihistamine-decongestant combination,
and in some cases, these medicines have
been associated with fatalities in children.6
Safety concerns with
children
Historically the use of cough and cold
medicine in children has been extrapolated
from adult practice (for indications and
dosage), due to the lack of available studies
in children.6 This is problematic for a number
of reasons; children metabolise medication
differently to adults (due to their size and
Childhood cough and cold
Pharmacist CPD
Module number 248
variation in enterohepatic circulation),
and although most cases of cough are due
to the common cold, in children, some
respiratory tract infections can be more
sinister – for example Bordetella pertussis.13
Unfortunately, to date, there is a lack of
evidence to conclude that OTC cough and
cold medicines are effective in children,
and in addition there is an absence of safe
dosage recommendations.14
The TGA found a lack of evidence of
efficacy for OTC cough and cold medicines
in children under the age of 12 years.15
In addition, the report concluded that
OTC cough and cold medicines have been
associated with adverse effects in children
such as:
When treating a child, medicines can often
be administered by multiple caregivers.
This increases the chances of medication
misadventure, especially because the vast
variety of preparations for cough and cold
generally contain similar ingredients.2
The use of cough and cold medicines in
children has been linked to numerous cases
of unintentional overdose and sudden
infant death.2,7,14 Following reports of
overdose and potentially life-threatening
adverse effects, in 2008 the US Food and
Drug Administration and the Therapeutic
Goods Administration (TGA) issued
warnings against the use of cough and
cold medicines in children younger than
two.2 Both agencies recommended use
with caution in children aged 2 to 11 due
to potential safety risks.2
• slow and shallow breathing
2012 TGA recommendations
Given the myriad of available evidence,
it is prudent that pharmacists are aware of
the safest and most effective treatments
for cough and cold in children. Due to
the limited evidence of efficacy and the
adverse effects of some medicines, the
TGA conducted a further investigation into
the use of cough and cold medicines for
children. In August 2012, the TGA published
final outcomes of a review conducted on
OTC cough and cold medicines for children
aged two to 12 years. This review concluded
that there are no immediate safety risks with
OTC cough and cold medicines for children;
however the TGA issued some warnings and
guidance on their use.15
• allergic reactions
• an increased or uneven heart rate
Facts Behind the Fact Card
Practice point 3
When to refer?2, 17, 18
• Any signs of a more serious viral or
bacterial infection:
-- high temperature (above
38.5 degrees Celsius)
-- ear ache
• drowsiness or sleeplessness
-- wheeze or difficulty breathing
(respiratory distress)
• confusion or hallucinations
-- sensitivity to light
• convulsions
-- sticky discharge from the eyes.
• nausea and constipation.15
The report identified that the potential
risks for use in children under six years was
greater than in older children; as such OTC
cough and cold medicine should not be
given to children under the age of six.15
For children aged six to 11 years, cough and
cold medicine should only be administered
following advice from a pharmacist, nurse
practitioner or doctor.12,15 There have been
no scheduling changes for OTC cough and
cold medicines as a result of this review.15
See Table 2 for all the medicines included
in the TGA review.
In addition to issues with efficacy and the
safety risk (including the risk associated
with overdose), the TGA concluded that
there are a number of other considerations
with the use of cough and cold medicines
in children. Children under the age of six
may need to seek medical assistance to rule
out more serious pathologies, such asthma,
bronchitis, or influenza, when they exhibit
the signs and symptoms of a common
cold.15 The TGA advised manufacturers to
ensure all cough and cold medicines have
child-resistant packaging, with correct
dosages for children aged six to 11 listed
on the label to avoid guesswork by parents
or caregivers.15
Table 2. Medicines included in TGA review15
Antihistamines
Antitussives
Expectorants/Mucolytics
Decongestants
Brompheniramine,
chlorpheniramine,
dexchlorpheniramine,
diphenhydramine,
doxylamine, pheniramine,
promethazine, triprolidine
Codeine,
dextromethorphan,
dihydrocodeine,
pentoxyverine,
pholcodine
Ammonium chloride,
bromhexine, guaifenesin,
ipecacuanha, senega and
ammonia
Oxymetazoline,
phenylephrine,
pseudoephedrine,
xylometazoline.
• Discoloured phlegm:
-- yellow/green – possible bronchitis.
-- rust – possible pneumonia
-- blood stained – possible
tuberculosis or lung cancer
-- pink/red – possible heart failure.
• Chest pain – important to exclude
cardiovascular disease.
• Pain when breathing in – important to
rule out pleurisy or pneumothorax.
• Paroxysms of coughing – important to
rule out pertussis.
• Barking cough that is worse at
night‑time and/or stridor – this could
be a sign of croup, whooping cough
or asthma.
• Cough that is worse in the morning
– this could be a sign of suppurative
lung disease.
• Cough more prevalent when feeding
and accompanied by reflux –
important to rule out GORD.
• Child is choking – may be associated
with a foreign body.
• Duration of the cough exceeds three
weeks – may be a persistent or chronic
cough with a serious underlying cause.
• Child has an accompanying rash or
mottled skin – essential to rule out
meningococcal disease.
• Child is showing signs of dehydration;
sunken fontanelles, lack of tears,
reduced urine output.
inPHARMation May 2014 I © Pharmaceutical Society of Australia Ltd.
7
John Bell
saysBehind the Fact Card
Facts
Childhood cough and cold
Practical implications for
pharmacists
the age of six (or, in this case dispenses the
prescription), this will constitute off-label
use.15 Off-label use is not illegal, however if
an adverse event occurs following off-label
use, the healthcare professional may have
difficulty justifying their actions.16
In light of the recent changes to the use
of cough and cold medicines for children,
pharmacists may find themselves in a
number of difficult situations with parents
and caregivers. It is integral that pharmacists
re-enforce the TGA findings to parents and
caregivers because there is new evidence
that shows these medicines will not benefit
children with a cough or cold, that there
are serious adverse effects that may occur
with the use of these products in children,
and the treatment of these symptoms may
delay the diagnosis of a more serious health
condition, such as asthma.12,15 The PSA
factsheet for changes to cough and cold
medicines provides a good summary and
scenarios to highlight the changes –
www.psa.org.au
In the event that a parent or caregiver
presents a prescription for a cough or
cold medicine for a child below the age
of six, pharmacists must use their clinical
knowledge and exercise professional
judgement when deciding whether or not
to dispense the prescription.12,16 In this
instance, given the recommendation of a
government body (the TGA) the pharmacist
should contact the prescriber to discuss the
individual case and alternative options.12,16
If a healthcare professional recommends
the use of such medicines in children below
Changes to cough and cold
medicines for children fact sheet
Available at www.psa.org.au
Changes to cough and cold medicines
for children
SEpt
2012
Factsheet
Therapeutic Goods Administration (TGA)
advice
1 September 2012
• Cough and cold medicines should not be given to children
under 6 years of age.
• Cough and cold medicines should only be given to
children aged 6 to 11 years on the advice of a doctor,
pharmacist or nurse practitioner.
Affected products
Type of medicine Active ingredients
Antihistamines
Brompheniramine, chlorpheniramine,
dexchlorpheniramine, diphenhydramine,
doxylamine, pheniramine, promethazine,
triprolidine
Antitussives
Codeine, dextromethorphan, dihydrocodeine,
pentoxyverine, pholcodine
Mucolytics/
expectorants
Bromhexine, guaiphenesin, ipecacuanha,
senega and ammonia
Decongestants
Phenylephrine, pseudoephedrine,
oxymetazoline, xylometazoline
Overview
The TGA has carried out a comprehensive review of the safety and efficacy of registered over-the-counter (OTC)
cough and cold medicines for children aged 2-12 years. As a result of this review, the TGA has concluded that there are
potential risks associated with these products for children and only limited benefits.
A number of changes have been recommended for the packaging and sale of these products which will have a significant impact on
community pharmacies. Pharmacists and pharmacy assistants must be informed of these changes and up skilled to enable them to respond
appropriately to customer queries.
PSA recommends that page 1 of this document be printed and used, if required, when counselling customers.
responding to customer queries
SCenAriO 1
SCenAriO 2
A customer presents in the
A customer presents to the
pharmacy with her 3-yearold daughter who has a cold.
She self-selects some liquid
cold and flu medicine and
brings it to the counter to
pay. You determine that the
medicine is for the child and
that she has used it before.
You inform her that it is no
longer recommended for
children under 6 years of age.
pharmacy and asks for
Other important information in the TGA review
X brand children’s cough
and cold medicine for his
• There are no immediate safety risks with these products.
4-year-old child. The child
• There is no proven benefit in using these products in children.
has typical cold symptoms –
• There are potential risks associated with these products for children.
fever, malaise, blocked nose
and a cough.
• Possible side effects include: allergic reactions; increased or uneven heart rate; slow and shallow breathing;
drowsiness or sleeplessness; confusion or hallucinations; convulsions; nausea; constipation.
• The above side effects are rare. However, overuse of these products or overdose can lead to serious harm.
• Using these products can also sometimes delay medical advice being sought for
more serious illnesses such as
issues
• Age of the child.
asthma, influenza, pneumonia, bronchitis or middle ear infection.
Her response
“The label has a dosing for 2-6 year olds so why can’t I have it?”
• Administration of medicines to ill children is a complex and
PSA3704
The labels of these products are being changed to reflect the new advice, but will take time to implement and be
ingrained behaviour – parents want something to ease the
phased in. Existing stock with the older labelling will still be allowed to be sold for usesymptoms
in adults of
and
children aged 6 years
a sick child.
and older until it is exhausted.
Options
For more information visit www.tga.gov.au/consumers/information-medicines-cough-cold.htm
1. Refuse the sale and give information as to why – show the
customer the TGA advice page.
2. Give customer information on alternative ways to care for
PSA
your
future.
a child
withEnabling
a cough and cold
e.g. control
temperatures
(paracetamol or ibuprofen), rest, maintain fluid intake, saline
nasal solutions.
• Age of child.
• Dosing instructions still on the product label.
• Customer has used it before with no adverse effects.
• How do you refuse the sale without losing the customer?
Options
1. Refuse supply knowing that the customer may choose to no
longer shop at your pharmacy.
3. Refer to doctor if child’s condition warrants this action.
2. Supply the product with counselling and record the sale.
(Not recommended)
responses
PDL’s response to option 2:
“I know that you want what is best for your child. However there
is new evidence that cough and cold medicines are of no benefit
to children and may have a risk of adverse effects. The new
recommendations are that cough and cold medicines should not
If a pharmacist recommended cough & cold medicine for a
2-6 year old child on or after 1 September 2012, knowing that
the regulations had changed, and an adverse event occurred,
this could be considered an intentional act and the claim may
be given to children under 6 years of age.”
be declined.
“Possible side effects include: allergic reactions; increased or
responses
uneven heart rate; slow and shallow breathing; drowsiness
As for Scenario 1.
or sleeplessness; confusion or hallucinations; convulsions;
“Cough and colds are self limiting conditions and will usually get
nausea; constipation.”
better by themselves. Ensure your child has plenty to drink and
“There are concerns that treating what appears to be the
gets enough rest to help them get better faster. Paracetamol
symptoms of coughs and colds in children with these medicines
or ibuprofen can be used to reduce your child’s temperature.
may delay the diagnosis and treatment of more serious conditions
For children who have a blocked nose, saline nasal drops are
such as asthma, pneumonia and meningococcal disease.”
available to help thin and clear nasal secretions.”
2
8
issues
I Changes to cough and cold medicines for children factsheet I © Pharmaceutical Society of Australia Ltd. I
September 2012
Pharmacist CPD
Best management of cough
and cold in children
Given the restrictions around the use of
cough and cold medicines, especially
for children under the age of six, it is
essential to review alternative treatment
options and self-care measures that can be
recommended to parents and caregivers.
Once the potential for more serious
pathologies has been excluded (See Practice
point 3), it is beneficial to explain the
typical causes of cough and cold to
parents or caregivers, and provide them
with a realistic expectation of symptom
duration (generally seven to 10 days).1,2
Pharmacists should assure parents and
caregivers that symptoms typically improve
and resolve spontaneously, and provide
them with advice on when they should
see a doctor if symptoms change or
worsen.2 Children should ideally rest and
stay home from childcare or school until
symptoms improve.2
Treatment options
Intranasal saline solution (saline drops) may
provide symptomatic relief of congested
nasal passages experienced in a common
cold.1,15 Saline drops work by softening
dry and thickened nasal secretions,
enabling mucus to be cleared.1 When
used in children, saline drops should be
administered in small volumes, to avoid the
risk of choking due to aspiration.1 Although
saline nasal drops have been shown to be
effective in chronic rhino sinusitis, there
is limited evidence for efficacy in the
common cold.2 However, they may provide
some symptomatic relief for children.
Soothing remedies, such as lozenges and
syrups, can be used to help relieve throat
soreness often experienced with the
common cold and associated cough.1
Demulcents (such as sucrose and glucose
syrups) form a coating (protective layer)
over the inflamed posterior pharynx and
often provide soothing relief for cold
sufferers.1,19,20 Additionally, they may
suppress the cough reflex due to the
inPHARMation May 2014 I © Pharmaceutical Society of Australia Ltd.
Module number 248
protection of sensory receptors in the
pharynx.20 It is important to note that no
studies have been published to support the
efficacy of these remedies. However due
to their high reported placebo effect, the
use of simple syrups may be used in young
children to provide symptomatic relief.1,20
Lozenges should be avoided in children
due to the risk of choking and aspiration.1
The use of steam and vapour in a closed
room or shower, may be effective in
the relief of nasal congestion.15 It is
postulated that water vapour may
soothe the nasal mucosa and have a
mucolytic action. However this theory
has little robust evidence.1 It is important
that this technique is conducted under
adult supervision due to the serious risk
of burns.2,15
Oral hydration fluids may assist with mucus
expectoration and thinning of respiratory
secretions.1,2,19,21 Children suffering from a
cold should be offered increased fluids to
assist with mucus expulsion and to avoid
dehydration (as children often consume
less food and fluid when unwell).21
Paracetamol or ibuprofen can be provided
to the child for relieving associated pain
or fever.2 Additionally, children should
avoid cigarette smoke exposure as this may
exacerbate cough symptoms.21
Parents and caregivers should be educated
about appropriate hygiene standards
to reduce the risk of the spread of viral
infections, such as the common cold.
Children should be encouraged to wash
their hands regularly with soap, particularly
after they blow their nose or cough,
and cover their mouth and nose when
coughing or sneezing (ideally with a tissue).
It is best to avoid sharing glasses or cups.22
The Cold and flu, Coughs, and Children’s
pain and fever PSA Self Care Fact Cards
can remind parents and caregivers of the
best treatment and self-care measures,
and increase awareness of symptoms that
require them to take their child to a doctor.
Natural remedies for cough and
cold in children
People often request natural medicines
for treating the common cold. Several
complementary and alternative medicines
can be used.
Childhood cough and cold
Pharmacist CPD
Module number 248
There is some evidence to show that
echinacea is an immune-modulator, which
increases the macrophagic activity of
neutrophils.23 To date, there are a limited
number of studies which establish the
efficacy or safety of echinacea in children.23
Of the studies that have been conducted in
children aged between two and 11, results
have shown little evidence of benefit and
an increased incidence of adverse effects,
namely allergic reactions.23 Therefore,
echinacea is not currently recommended
for use in children for the treatment of the
common cold.
Vitamin C has a protective effect on the
immune system (against oxidative stress)
and may also stimulate phagocytosis to
assist elimination of foreign pathogens.24
It has been used for many years to prevent
and treat common cold symptoms.
Current evidence shows that regular
supplementation with greater than or
equal to 2 g of vitamin C per day leads
to a 14% reduction in duration of the
common cold in children.26 However
given the level of this evidence, long-term
supplementation with vitamin C in children
is not warranted.24 In addition, there are a
lack of studies conducted in children that
review the benefit of vitamin C use during a
common cold.24
Some studies have shown that zinc is
effective in reducing the severity of cold
symptoms, particularly in children.25,26
However there are some reports that zinc
has no effect on cold symptoms.26 The exact
mechanism by which zinc exerts its effect
is unknown, however it is postulated that
zinc stimulates the immune system.26
Unfortunately there is insufficient evidence
available to support the safety of zinc in
children. Routine administration of zinc for
children suffering from the common cold is
not recommended.26
If a child is able to tolerate hot drinks, a
home remedy such as lemon and honey tea
may be suitable to soothe a sore throat.1
There is no evidence that these remedies
improve cold symptoms, however they may
provide symptomatic relief.1
Practice point 4
PPI link
This case scenario represents a situation
where a pharmacist has performed a
Clinical Intervention. The pharmacist
has advised this mother against the
use of Demazin for her three-year-old
child, explained the rationale behind
this recommendation and provided
information in the form of Self Care
Fact Cards.
Drug Related Problem
Category
Subcategory
Code
Drug selection
Other drug
selection
problem
D0
Case study
Jenny, a young mother, comes to the
pharmacy to request Demazin cough and
cold syrup for her two sons. Her children
have been unwell with a cold for a few days
now and Jenny would like something to
help relieve their symptoms. You ask Jenny
a series of questions to elicit a detailed
history for the children, and discover:
Recommendations
Category
Subcategory
Code
Change of
therapy
Drug change
R3
Referral
required
Education or
counseling
session
R12
Provision of
information
Other written
information
R16
• her children are aged three and
eight years
• both children have felt lethargic, had a
runny nose and a dry cough for the past
2–3 days
• they take no other medicines and have
no medical conditions or allergies
• Jenny gave her eight-year-old Demazin
when he was younger and found this
product to be very effective.
You advise Jenny that her two children
are probably suffering from a common
cold. You also inform Jenny of the new
evidence around the use of cough and
cold medicines in children. In particular,
you explain that these medicines have
little evidence of benefit in children and
they may cause side effects. Possible
adverse effects in children include –
allergic reactions, an increased or uneven
heart rate; slow and shallow breathing;
drowsiness or sleeplessness; confusion
or hallucinations; convulsions; nausea
and constipation. In addition cough and
cold medicines are best avoided in young
children due to the risk of missing a more
serious underlying health condition such as
asthma or pneumonia.
Related Fact Cards
Colds and flu
Coughs
Children’s pain and fever
inPHARMation May 2014 I © Pharmaceutical Society of Australia Ltd.
9
John Bell
saysBehind the Fact Card
Facts
Childhood cough and cold
Pharmacist CPD
Module number 248
You advise Jenny that these medicines
should not be used for children under
the age of six (her three-year-old), but
in some cases, you can recommend
Demazin for children aged six to 11 (her
eight‑year‑old). However, you explain that
a common cold is a self-limiting condition,
and symptoms usually resolve on their
own within seven to 10 days. You offer
Jenny some saline nasal drops to clear and
thin nasal secretions, some paracetamol
or ibuprofen for any associated pain or
fever, and advise her that she should offer
more fluids to the children to ensure they
remain well hydrated. You inform Jenny
that the use of steam or vapour (under
supervision) may help to relieve nasal
congestion. In addition, you recommend
some simple linctus to soothe the children’s
sore and dry throat, and to assist with their
cough. You remind Jenny to encourage
her children to cover their mouth with a
tissue when they cough and to wash their
hands regularly to minimize the spread of
infection. Finally, you inform Jenny that if
either child’s condition worsens they may
need to see a doctor. You provide her with
PSA Self Care Fact Cards – Colds and flu,
Coughs and Children’s pain and fever.
References
1. Department of child and adolescent health and
development. World Health Organization. Cough and cold
remedies for the treatment of acute respiratory infections in
young children. Switzerland; 2001.
2. Sung V, Canswick N. Cough and cold remedies for children.
Aust Prescr 2009;32(5):122–4.
3. Australian Bureau of Statistics. Health of Children, 2004. At:
www.abs.gov.au/ausstats/[email protected]/ProductsbyReleaseDate/
BFDEA1987337522ECA2572820014F0FF?OpenDocument
4. Kelly L, Allen P. Managing acute cough in children: evidence
based guidelines. Paediatr Nurs 2007;33(6):505–24.
5. Respiratory Expert Group. Therapeutic guidelines:
respiratory. Version 4. Melbourne: Therapeutic Guidelines
Ltd; 2009.
6. Therapeutic Goods Administration. Review of cough and
cold medicines in children. Apr 2009. At: www.tga.gov.au/
pdf/archive/consult-labelling-cough-cold-091022-review.
pdf
7. Cranswick N, McGillivray G. Over-the-counter medication in
children: friend or foe? Aust Prescr 2001;24:149–51.
8. Isbitser G, Prior F, Kilham A. Restricting cough and cold
medicines in children. Journal Paediatr Child Health
2012;48:91–8.
9. Smith SM, Schroeder K, Fahey T. Over-the-counter (OTC)
medications for acute cough in children and adults
in ambulatory settings. Cochrane Database Syst Rev
2008;(1):CD001831.pub3.
10.Hutton N, Wilson M, Mellitis E, Baumgardner R. Effectiveness
of an antihistamine-decongestant combination for younger
children with the common cold: a randomised controlled
clinical trial. J Pediatr 1991;118:125–30.
11.Clemens CJ, Taylor JA, Almquist JR, Quinn HC, Mehta A,
Naylor GS. Is an antihistamine-decongestant combination
effective in temporarily relieving symptoms of the common
cold in preschool children? J Pediatr 1997;130:463–6.
12.Pharmaceutical Society of Australia. Fact sheet – Changes to
10
cough and cold medicines for children. Sep 2012. At: www.
psa.org.au/download/codes/cough-and-cold-medicines-forchildren-factsheet-sept-2012.pdf
13.National Prescribing Service. Over-the-counter cough and
cold remedies – not for young children. Nov 2012. At: www.
nps.org.au/health-professionals/health-news-evidence/2012/
over-the-counter-cough-and-cold-remedies-not-for-youngchildren
14.Centers for Disease Control and Prevention. Infant deaths
associated with cough and cold medications – two states,
2005. MMWR 2007;56:1–4
15.Therapeutic Goods Administration. OTC cough and cold
medicines for children - Final outcomes of TGA review. Aug
2012. At: www.tga.gov.au/industry/otc-notices-cough-coldreview-outcomes.htm#.UumTvty4a70
16.Pharmacy Guild of Australia, Pharmaceutical Defence
Limited, Pharmaceutical Society of Australia. Information
for pharmacy staff: changes to the use of cough and
cold medicines in children. Sep 2012. At: www.pdl.org.
au/publications/coughs_and_cold_medication_2012/
download/id/233
17.Pharmaceutical Society of Australia. Non-prescription
medicines in the pharmacy – a guide to advice and
treatment. Canberra: The Pharmaceutical Society of
Australia; 2012.
18.Rutter P, Newby D. Community pharmacy. Symptoms,
Diagnosis and Treatment. 2nd edn. Sydney: Churchill
Livingstone; 2011.
19.Sansom LN ed. Australian pharmaceutical formulary and
handbook. 22nd edn. Canberra: Pharmaceutical Society of
Australia; 2012.
20.Rossi S, ed. Australian medicines handbook. Adelaide:
Australian Medicines Handbook; 2013. At: www.amh.net.au/
online/view.php?=index.html
21.Pharmaceutical Society of Australia. Non-prescription
medicines in the pharmacy – a guide to advice and treatment.
inPHARMation May 2014 I © Pharmaceutical Society of Australia Ltd.
Canberra: The Pharmaceutical Society of Australia; 2012
22.Nathan A. Non-prescription medicines. 4th edn. London:
Pharmaceutical Press; 2010.
23.Weber W, Taylor J, Stoep A, Weiss N, Standish L, Calabrese
C. Echinacea purpurea for prevention of upper respiratory
tract infections in children. J Altern Complement Med
2005;11(6):1021–6.
24.Kurugol Z, Akilli M, Bayram N, Koturoglu G. The prophylactic
and therapeutic effectiveness of zinc sulphate on common
cold in children. Acta Paediatrica 2006;95:1175–81.
25.Kurugol Z, Bayram N, Atik T. Effect of zinc sulfate on common
cold in children: randomized double blind study. Pediatr Int
2007;49:842–7.
26.Hemila H, Chalker E. Vitamin C for preventing and treating
the common cold (review). Cochrane Database of Systematic
Reviews 2013; Issue 1. Art. No.: DOI: 10:1111/j.1442200X.02448.
Childhood cough and cold
Pharmacist CPD
Module number 248
Facts Behind the Fact Card
Assessment questions for the pharmacist
Childhood cough and cold
Personal ID number:
— — — — — —
Full name:. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Pharmacy:.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Address:. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Suburb:. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . State:.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Postcode:. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Circle one correct answer from each
of the following questions.
Before undertaking this assessment, you need
to have read the Facts Behind the Fact Card
article and the associated Fact Cards.
This activity has been accredited by PSA as a
Group 2 activity. Two CPD credits (Group 2)
will be awarded to pharmacists with four out
of five questions correct. PSA is accredited by
the Australian Pharmacy Council to accredit
providers of CPD activities for pharmacists
that may be used as supporting evidence of
continuing competence.
1. First generation antihistamines:
a) are extremely effective antitussive
agents.
b) have been associated with sudden
infant death syndrome in children
aged below two years.
c) are not routinely recommended for
use in children, due to safety and
efficacy concerns.
d) Both B and C are correct.
2. Pholcodine is a centrally acting
cough suppressant which:
a) can cause sedation and allergic
reactions in children.
b) decreases the cough threshold in
the medulla.
c) is a safe and effective cough
treatment for children.
d) has been studied extensively for
use in children.
Assessment due 30 June 2014
Submit answers
Submit online at www.psa.org.au/selfcare
Fax:
02 6285 2869
Accreditation number: CS140004
This activity has been accredited for Group 2 CPD
(or 2 CPD credits) suitable for inclusion in an individual
pharmacist’s CPD plan.
Mail: Self Care Answers
Pharmaceutical Society of Australia
PO Box 42
DEAKIN WEST ACT 2600
Please retain a copy for your own purposes.
Photocopy if you require extra copies.
3. Beverley’s five-year-old daughter
has a dry cough, runny nose and
slight fever. She would like to
purchase some medicines to relieve
her daughter’s symptoms. Which of
the following is NOT appropriate to
recommend for her daughter?
a) Intranasal saline drops.
5. In 2012 the TGA implemented
changes to the recommendations
for OTC cough and cold medicines in
children. These included:
a) There are immediate safety risks
associated with the use of OTC
cough and cold medicines in
children.
b) OTC cough and cold medicine
have now become Schedule 3
medicines.
b) Simple linctus.
c) Echinacea drops.
d) Paracetamol.
4. In which of the following situations
would you refer the patient to a doctor?
a) 11-year-old child with a dry cough
and runny nose for the past two days.
b) eight-year-old child with a blocked
nose, malaise and fever for the past
four days.
c) seven-year-old child with a dry
cough which is worse at night time
for the past seven days.
c) OTC cough and cold medicines
cannot be used in children
aged 2–12, even upon medical
recommendation.
d) OTC cough and cold medicine is
not recommended for children
below the age of six, but can
be recommended for children
aged 6–11, upon advice from a
pharmacist, nurse practitioner or
doctor.
d) four-year-old child with fever
(38 degrees Celsius) and sore
throat for the past three days.
inPHARMation May 2014 I © Pharmaceutical Society of Australia Ltd.
11
John Bell says
Counter Connection
Childhood cough and cold
Pharmacy assistant’s education
Module 248
Childhood cough and cold
By Sarah Curulli
This education module is independently researched and compiled by PSA-commissioned authors and peer reviewed.
Parents and caregivers often
come to pharmacy requesting
medicines for their children. As the
pharmacy assistant, you play a
vital role in this process, and with
your knowledge and skills, you
can guide parents and caregivers
appropriately.
You can now print a certificate upon
successful completion of Counter
Connection modules and include in
your training records for QCPP.
Download yours today at:
www.psa.org.au/selfcareeducation
New evidence shows that OTC cough and cold medicines are not always suitable for children.
Causes and symptoms
The cold is a very common health condition
in children. It is a short-term illness that is
caused by viruses which attack the immune
system, leading to symptoms such as a
runny or blocked nose, fever, sore throat,
sneezing, cough and a general feeling of
tiredness and lack of energy. The most
troublesome symptom of a cold is usually
an irritating cough.
A cough is the body’s way of protecting the
lungs from foreign bodies and infections.
When a child coughs, their body is trying
to clear the infection from the lungs and
airways. The cold is the most common
cause of a cough. However, other causes of
a cough include; asthma, bronchitis, acid
reflux and some medicines.
CHILDREN’S HEALTH
Children’s pain and fever
Pain and fever are common symptoms of many childhood medical conditions.
Pain and fever can make a child feel miserable. There are medicines and
non-medicine ways to help your child feel better. Ask a doctor, pharmacist or
nurse for advice.
Pain
EAR, NOSE & THROAT
Coughs
A parent’s instincts can also help them
know when their child is in pain.
Causes
Treatment
Children of all ages feel pain.
Medicines can help relieve pain,
Pain is usually caused by injury or
but there are also non-medicine
illness, but sometimes children feel
ways to help your child manage pain.
strong emotions and stress as pain
For example:
(e.g. stomach ache). Pain can frighten
The common
and cigarette
• Givecold,
your allergy
child plenty
of cuddlessmoke
and are common causes of
a child, and fear can make pain worse.
coughing,attention.
but a cough can also be a symptom of a serious illness or a side
If a child complains of pain, take
effect of•aLet
medicine.
Treatment
a cough
your child
know it isfor
okay
to cry depends on its cause.
them seriously.
when they are in pain.
Coughing is a normal reflex to protect
Signs
It can be hard to know when a child,and clean our airways (respiratory
especially a young child, is in pain. tract). Coughing clears irritating
material (e.g. smoke or dust) and excess
Changes in a child’s mood and
secretions (mucus, sputum, phlegm)
behaviour can be signs of pain. A child
from our throat, air passages and lungs.
may show pain by:
The sound and pattern of a cough
• what they say
depends on its cause.
• what they do (e.g. cry, hold the sore
part, stop playing, eat less, sleep less,
Causes of coughing
become quiet or irritable)
Cough is a symptom of a number
• how their body is reacting (e.g. pale,
of medical conditions. Sometimes a
sweating, fast pulse).
person may have more than one reason
for coughing.
Causes of coughing include:
• post-nasal drip – mucus from the
nose and sinuses runs down the back
of the throat. Often caused by allergy,
common colds or sinus infection
• asthma
• respiratory tract infections (e.g. colds,
bronchitis, croup, whooping cough,
pneumonia)
• inhaled irritants (e.g. cigarette smoke,
dust, fumes, a foreign object)
12
• lung disease (e.g. cystic fibrosis,
chronic bronchitis, cancer)
• gastro-esophageal reflux (heartburn)
– stomach acid rises up into the
oesophagus and causes coughing
• heart failure
• anxiety and habit
• some medicines (e.g.
anti-inflammatory pain relievers and
some blood pressure medicines).
Colds are extremely contagious; children
can often pass the infection on to others
through coughing and sneezing. A cold can
spread to multiple children (and adults)
at childcare or school, or between
family members in the same household.
Fortunately, symptoms of the cold usually
improve and disappear on their own, usually
in about 7 to 10 days.
inPHARMation May 2014 I © Pharmaceutical Society of Australia Ltd.
Recent recommendations
for cough and cold
medicines in children
For many years over-the-counter (OTC)
cough and cold medicines have been
recommended for children. However,
in the past six years some evidence has
emerged that shows these medicines are
not always suitable for children. In 2012,
the Therapeutic Goods Administration
(TGA), an Australian government body,
released new information for healthcare
professionals when recommending OTC
cough and cold medicines for children.
The medicines included in the review are
shown in Table 1.
The TGA reported:
• There are no immediate safety risks with
the use of OTC cough and cold medicines
in children.
• OTC cough and cold medicines are not
proven to be effective for children –
they do not appear to improve symptoms
or reduce the duration of a cough or cold.
• There are some safety concerns
associated with the use of these
Childhood cough and cold
Pharmacy assistant’s education
medicines in children (for example
– some cases of overdose have been
recorded, and this has been linked to
sudden infant death syndrome).
• OTC cough and cold medicines should
never be recommended for children
below the age of six years.
• Children aged 6–11; OTC cough and cold
medicines can only be recommended
upon the advice from a pharmacist, nurse
practitioner or doctor.
Module 248
and cold medicine, refer the request to the
pharmacist. These medicines can only be
provided after the pharmacist has assessed
the situation and recommended them.
You should also refer the customer to
the pharmacist if the child has any of the
following:
• high fever (above 38.5 degrees Celsius)
• ear ache
• wheeze, chest pain or trouble breathing
The TGA also highlighted some other
reasons why OTC cough and cold medicines
should be used with caution in children.
Symptoms of a cold in young children
(below the age of six) may be the sign of
another more serious health condition, such
as asthma or bronchitis. Also, children can
often be given medicines by a variety of
adults (such as childcare workers, parents
or grandparents), and this increases the
chance of a dosage error occurring.
• discharge from the eyes
When to refer to the
pharmacist
What treatment options can
you recommend?
In some cases, children who have the signs
and symptoms of a cold may be suffering
from a more serious health complaint.
It is important to be able to recognise any
symptoms that may not be normal for a
cold, so that you can be confident to refer
the request to the pharmacist.
Firstly, it is important to remind parents
and caregivers that symptoms of the cold
usually improve on their own in about
7–10 days. Provide customers with the
Colds and flu, Coughs and Children’s pain
Given the new recommendations from the
TGA, if a parent or caregiver requests an OTC
cough and cold medicine (such as Demazin,
Dimetapp or Phenergan) you should confirm
the age of the child, or children, requiring
treatment.
If the child is below the age of six, you
should advise the customer that you cannot
recommend this product in this age group,
because:
• coloured phlegm (yellow, green, pink
or red)
• cough that is worse in the morning or at
night time
• choking
• other symptoms – acid reflux, rash, signs
of dehydration (sunken eyes, lack of tears,
reduced urine output, dark yellow urine)
• cough for longer than three weeks.
• use of these medicines in young children
may reduce the chance of discovering an
underlying condition (such as asthma or
bronchitis).
If the customer would like more
information, refer them to the pharmacist.
If the child is aged 6–11 years, and the
parent or caregiver requests an OTC cough
and fever PSA Self Care Fact Cards as these
documents contain important information
about treatment, self-care and what to do
if their child’s condition worsens. There are
some treatment options that the pharmacy
assistant can recommend for children:
Nasal saline drops (e.g. Fess Little Noses,
Narium Baby) – These can loosen mucus,
which can help to relieve a blocked nose
and clear phlegm. These products are often
packaged with a bulb syringe, which can
be used to suck the mucus out of the nose
(ask the pharmacist for more information).
Soothing syrups (e.g. Simple linctus) – Forms
a protective coating over the throat which
may soothe a sore throat and ease a cough.
Paracetamol or ibuprofen (e.g. Panadol or
Nurofen) – Will relieve any pain and fever
that the child may be experiencing.
Parents and caregivers may request a
natural medicine (herbal or vitamin remedy)
to prevent or treat a cold in children.
You should advise them that there is not
enough scientific evidence to show that
natural medicines (such as Echinacea,
vitamin C and zinc) are effective in the
prevention and treatment of a cold in
children. If they have any further questions,
they can be referred to the pharmacist.
Table 1. Medicines included in TGA review
Medicine class
Medicines
Examples
Antihistamines
brompheniramine
Dimetapp elixir
chlorpheniramine
Demazin cold relief syrups
dexchlorpheniramine
Polaramine syrup
diphenhydramine
Benadryl original
doxylamine
Mersyndol tablets
pheniramine
Avil tablets
promethazine
Phenergan elixir
Antitussives
• these medicines have not been proven
to work in children for the treatment of a
cough or cold
• they may cause some serious side effects
Counter Connection
Expectorants/Mucolytics
Decongestants
triprolidine
Codral original day and night tablets
codeine
Painstop for children
dextromethorphan
Robitussin dry cough forte
dihydrocodeine
Rikodeine oral liquid
pentoxyverine
Nyal dry cough medicine
pholcodine
Duro-Tuss dry cough liquid
ammonium chloride
Chemists own expectorant
bromhexine
Bisolvin Chesty oral liquid
guaifenesin
Vicks chesty cough syrup
ipecacuanha
Gold Cross ipecacuanha and tolu mixture
senega and ammonia
Senagar
oxymetazoline
Drixine nasal spray
phenylephrine
Paedamin syrup
pseudoephedrine
Demazin cold and flu syrup
xylometazoline
FLO Xylo-POS nasal spray
inPHARMation May 2014 I © Pharmaceutical Society of Australia Ltd.
13
John Bell says
Counter Connection
Childhood cough and cold
Pharmacy assistant’s education
Module 248
In the meantime, you provide Jenny with
Colds and flu, Coughs and Children’s pain and
fever PSA Self Care Fact Cards which contain
important information about treatment
options, self-care measures, and what to do
if the children’s symptoms change or get
worse. You inform Jenny that most colds
usually go away on their own in about
7–10 days.
You encourage her to ask the children to:
• wash their hands regularly (with soap)
• cover their mouth when coughing or
sneezing (with a tissue)
• avoid touching their mouth, nose or eyes
• avoid sharing glasses or cutlery, as
this can help to reduce the spread of
infection.
What are the self-care
options?
You can also advise parents and caregivers
of the following self-care options:
Steam and vapour – The use of a vapouriser
in a closed room, or steam vapour in the
shower, may soothe the inside of the nose
and thin any mucus. Important – Due to the
risk of burns, this must be conducted under
adult supervision.
Oral hydration fluids – It is important to
ensure that children remain well hydrated
when suffering from a cold. This helps
to thin mucus, and also avoids the risk
of dehydration, which can occur if the
child eats and drinks less when they feel
unwell. Babies should be offered water
between feeds.
Rest – A child with a cough or cold should
get plenty of rest and should be kept
comfortably warm.
Avoid cigarette smoke – this can make
symptoms worse.
Hygiene – Encourage children to wash their
hands regularly (with soap), especially after
they blow their nose or cough. They should
also cover their mouth (preferably with a
tissue) when they cough. Children should
avoid touching their eyes, nose or mouth
with their hands and should avoid sharing
cups, glasses or cutlery. These measures
should reduce the risk of the infection
spreading to other people (especially other
family members or caregivers).
14
Case study
Jenny, a young mother, comes to the
pharmacy to request Demazin cough and
cold syrup for her two sons. Her children
have been unwell with a cold for a few days
now, and Jenny would like something to
help relieve their symptoms. You ask Jenny a
series of questions, and discover:
• her children are thee and eight years old
• both children have felt very tired, had a
runny nose and a dry cough for the past
2–3 days
• they take no other medicines and have no
medical conditions or allergies
• Jenny gave her eight-year old son
Demazin when he was younger and found
this product to be very effective.
You tell Jenny that it sounds like her
children have a cold. You inform her of
the new evidence that has been reported
about OTC cough and cold medicines for
children. You advise her that you cannot
recommend Demazin for her three-year-old.
In children below the age of six medicines
such as Demazin have not been proven to
work for the cold, and may cause serious
side effects. Also, the use of these medicines
in young children may reduce the chance
of discovering an underlying health
condition, such as asthma or bronchitis.
You also advise Jenny that these medicines
may be used in children aged 6–11 years
after the recommendation by a healthcare
professional, and you offer to refer her
request to the pharmacist to discuss
treatment for her eight-year-old.
inPHARMation May 2014 I © Pharmaceutical Society of Australia Ltd.
You recommend the use of some nasal
saline drops (to relieve a runny or blocked
nose), some simple linctus (to soothe
the throat and ease the dry cough) and
paracetamol or ibuprofen (for any pain or
fever). You also advise Jenny that the use of
steam or vapour with a vapouriser (under
supervision) may help to relieve symptoms.
Jenny should make sure the children drink
enough fluids while they are sick (to prevent
dehydration and help thin mucus in their
nose and chest). Lastly you inform Jenny
that it is important to avoid cigarette smoke,
as this may make their coughs worse.
PPI Link – Health promotion
campaign
Some OTC cough and cold medicines
have been linked to overdose and
sudden infant death. To raise awareness
of the new TGA recommendations,
and to help customers understand
why these changes have been made,
your pharmacy could conduct a health
promotion campaign on sudden infant
death syndrome (SIDS) with a possible
link to red nose day.
www.rednoseday.com.au
Childhood cough and cold
Pharmacy assistant’s education
Counter Connection
Module 248
Assessment questions for the pharmacy assistant
Childhood cough and cold
Personal ID number:
— — — — — —
Full name:. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Pharmacy:.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Address:. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Suburb:. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . State:.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Postcode:. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Circle one correct answer from each
of the following questions.
Before undertaking this assessment, you
need to have read the Counter Connection
article and the associated Fact Cards.
The pass mark for each module is five
correct answers. Participants receive one
credit for each successfully completed
1. Symptoms of the cold include:
a) runny or blocked nose.
b) cough.
c) fever.
d) all of the above.
2. The TGA recommendations include:
a) All children who have a cough or
cold need to see a doctor.
b) OTC cough and cold medicine
should not be given to children
under the age of six.
c) There are some immediate safety
risks with the use of cough and
cold medicines in children.
d) Cough and cold medicines
are very good at treating cold
symptoms in children.
Submit answers
module. On completion of 10 correct
modules participants receive an
Achievement Certificate.
Submit online at www.psa.org.au/selfcare
Fax:
Assessment due 30 June 2014
02 6285 2869
Mail: Self Care Answers
Pharmaceutical Society of Australia
PO Box 42
DEAKIN WEST ACT 2600
Please retain a copy for your own purposes.
Photocopy if you require extra copies.
3. Patricia’s child has a cold. She has a
blocked nose, sore throat, sneezing
and fever (temperature of 39
degrees Celsius). You refer Patricia
to the pharmacist because of which
symptom?
a) Blocked nose.
b) Sore throat.
5. Which of the following cannot
be recommended by a pharmacy
assistant?
a) Demazin for a three-year-old with a
cold.
b) Fess Little Noses for a six-year-old
with a cold.
c) Sneezing.
c) Panadol for a four-year-old with a
cold.
d) Fever (temperature above 39
degrees Celsius).
d) Nurofen for a five-year-old with a
cold.
4. Michael’s son has had a cold for two
days. He has a cough, ear ache, feels
tired and has a runny nose. You refer
Michael to the pharmacist because of
which symptom?
a) Cough.
b) Ear ache.
c) Tiredness.
6. Which of the following can help
with cough and cold symptoms in
children?
a) Soothing syrups.
b) Oral hydration.
c) Steam and vapour.
d) All of the above.
d) Runny nose.
inPHARMation May 2014 I © Pharmaceutical Society of Australia Ltd.
15
John Bell says Noticeboard
Self Care achievers
Year 5
Self Care presents certificates to staff who successfully complete a
year of Counter Connection modules. We would like to congratulate
the following people:
Year 12
Year 9
Year 6
Jodie Senn
Thea Dimopoulos
Cindy Riley
Kaye Millen
Rebecca Smith
Wendy Hodge
Nola Woodward
Sarah Anderson
Nicole Vogel
Wendy Moore
Jenny Kearney
Carla Rauchle
Year 11
Lyn Halliday
Cheryl Ackland
Year 8
Year 10
Year 7
Nada Bojceska
Tanya Lehane
Wendy Honeybone
Hellen Smythe
Jenny Adcock
Jenny Barrow
Marita Hanson
Kerry-Anne Purvis
Cheryl Kimmince
Scott Donatti
Sue Brown
Year 4
Lana Tamindzic
Michelle Wilson
Year 3
Danielle Powell
Kelly Matthews
Eleanor Barillas
Suzanne Peattie
Abby Brown
Debbie Brooks
Julie-Ann Tomlinson
Conferences and calendar dates
Conferences
Conferences
The Victorian Pharmacy Conference
25th FAPA Congress
17–18 May
Parkville, Melbourne, VIC
www.psa.org.au
9–12 October
Kota Kinabalu , Sabah, Malaysia
www.fapa2014.com
39th PSA Offshore Refresher Conference
PAC14
20–30 May
New York and Washington
www.psa.org.au
10–12 October
National Convention Centre, Canberra ACT
www.psa.org.au/pac
National Medicines Symposium 2014
21–23 May
Brisbane Convention and Exhibition Centre, Qld
www.nps.org.au/nms
National health calendar dates
May
The 13th National Rural Health Conference
17
24–27 May
Darwin Convention Centre, NT
www.ruralhealth.org.au/13nrhc
World Hypertension Day
Kidney Health Australia
www.kidney.org.au
21–23
Connecting practice to patient outcomes
30 May–1 June
Sydney, NSW
www.psa.org.au/cpexpo
National Medicines Symposium
NPS MedicineWise
www.nps.org.au
22
Pharmacy 2014 – The Pharmacy
Management Conference
Australia’s Biggest Morning Tea
Cancer Council
www.cancercouncil.org.au
31
World No Tobacco Day
World Health Organization
www.who.int/tobacco/wntd/en/
CPExpo14
30 July–1 August
Surfers Paradise Marriott Resort & Spa, Qld
HIC 2014
11 – 14 August
Melbourne, VIC
www.hisa.org.au/hic2014
June
All month
74th FIP World Congress 2014
Access to medicines and pharmacists today,
better outcomes tomorrow.
30 August – 4 September
9
9–15
27
Bowel Cancer Awareness Month
www.bowelcanceraustralia.org
Queen’s birthday
Men’s Health Week
www.menshealthweek.org.au
Red nose day
www.rednoseday.com
16
inPHARMation May 2014 I © Pharmaceutical Society of Australia Ltd.
Rebecca Honeywood
Melanie Evans
Year 2
Jennifer Krisko
Paca Gorgievska
Angela Malone
Janet Shepherd
Deirdre Evans
Bianca Weller
Courtney Forrester
Jessie McConnell
Amanda Xibberas
Brittany McIntosh
Bianca Dolezal
Amy-Rose Collins
Stefanie Nix
Natalie Ballard
Kathlene Niall
Helen Sharp
Jessica Magee
Lyn Horne
Katrina Leader
Linda McKeddie
Year 1
Debbie Hodge
Tina Thomas
Danielle Allen
Kristin Sheldon
My Tran
Kym Minogue
Jackie Birdling
Kara Hill
Cherie Douglas
Sally Marks
What’s coming up
in inPHARMation?
Next month’s inPHARMation
will focus on early onset
diabetes type 2 in Australia.
Obesity in Australia is at
epidemic proportions and is
now translating into a rise in
the number of diagnoses of
type 2 diabetes, particularly
in the younger generation.
This inPHARMation will discuss
the complications, health
outlook and communication
strategies for the younger
diabetic, along with an update
of the medications, monitoring
and lifestyle measures needed to
manage the condition.