Oral antihistamine–decongestant–analgesic combinations for the common cold—do they work?

…reducing waste in child health one intervention at a time



Eco-paediatrics is an occasional feature in Evidence-Based Child Health: A Cochrane Review Journal. Our goal is to contribute to the worldwide discussion on reducing waste in health care. In each instalment, we will select a recent Cochrane review highlighting a practice, still in use, which the available evidence tells us should be discontinued.

Excerpts from: De Sutter AIM, van Driel ML, Kumar AA, Lesslar O, Skrt A. Oral antihistamine-decongestant-analgesic combinations for the common cold. Cochrane Database of Systematic Reviews 2012, Issue 2. Art. No.: CD004976. DOI: 10.1002/14651858.CD004976.pub3.

Common cold

The common cold is probably the most common illness known. There are a range of symptoms including sore throat, nasal stuffiness and discharge, sneezing and cough. Fever is fairly common in children (1). On average, young children have six to eight cold bouts a year and adults have two to four (1,2).

Oral antihistamine–decongestant–analgesic combinations

There is no widely available cure or vaccination for the common cold. Combinations of antihistamines, decongestants and analgesics are used to relieve the broad spectrum of common cold symptoms.

What should we do in practice?

In young children, these combinations should not be used as there is no evidence of effectiveness and they are potentially unsafe (e.g. increased sleepiness). Scarce data showing some benefit of antihistamine–analgesic–decongestant combinations in improving general symptoms in older children need to be weighed with the risk of adverse events and the benign course of the common cold. Combinations containing phenylpropanolamine must be avoided because of the increased risk of intracranial bleeding (3).

What do the guidelines suggest?

American Academy of Pediatrics (4)Cough and cold medicines should not be prescribed or recommended for respiratory illnesses in children under 4 years of age. Research has shown that these products offer little benefit to young children and can have potentially serious side effects. Many cough and cold products for children have more than one ingredient, increasing the chance of accidental overdose if combined with another product.
Canadian Paediatric Society (5)Despite their widespread use among children, the use of over-the-counter cough and cold medications is not effective in most cases and is potentially harmful.

Evidence-Based Child Health, Editorial Office

*Correspondence to: Evidence-Based Child Health Canadian editorial office. E-mail: child@ualberta.ca

Commentary by R. Fernandes

In an era of whole-genome sequencing and targeted biological drugs, it is frustrating to watch as each wave of rhinovirus infections inevitably leads to hordes of coughing children, tired parents and powerless physicians. The prospect of a benign prognosis is hardly enough, given the impact of the common cold on everyday life. And time and again, over-the-counter drugs capitalize on the tempting prospect of a quick recovery. Throughout the world, an assortment of different individual or combined formulations is available under different generic or trade names, offering the promise of a ‘specific’ effective treatment. Many parents will initiate these treatments at home at the first sign of their child's symptoms. Older children and adolescents may do so autonomously, often without adequate guidance.

However, a fair look at the evidence clearly shows most of these drugs provide scarce benefit, while entailing significant safety risks. Antihistamines and decongestants fall under this category, and the safety issues of decongestants in young children are well known. Combined formulations have added risks—they provide a false illusion of synergism, but many parents are unaware that they are giving multiple drugs.

Rational prescribing for the common cold means focusing on safe and effective symptomatic treatments (e.g. analgesics) and excluding the rest. While you can wonder why some of these combinations are still on the market, clinicians cannot be mere bystanders in over-the-counter drug usage and should promote their rational use by parents and children.

Declaration of interest

No conflicts of interest.