Posted by & filed under Noah's Notes.

That was one of my Dad’s favorite aphorisms, and a recent article brought that particular quote to mind. “Adverse events associated with opioid-containing cough and cold medication in children” was published in April’s online version of Clinical Toxicology.

Opioid containing cough syrups (Robitussin AC, Tussionex and others) have been around for a long time and are widely used, despite the fact that other studies show that they are ineffective in reducing cough. The risks of these drugs are elevated in children but their use has persisted. In this current study they looked at US cases of adverse events in children related to these cough medications between 2008 and 2015. The results were:

  • 114 of 7035 cases reviewed involved an opioid containing product.
  • In 98 cases the adverse event could reasonably be linked to the opioid.
  • There were 3 deaths and all involved a cough medicine combination of an antihistamine and hydrocodone (the opioid in Tussionex).
  • Other adverse events included somnolence, lethargy, lethargy (all also more common with hydrocodone than with codeine).

In January of this year the FDA required warning labels on these cough medicines to attempt to limit their use in children under the age of 18 and included their highest level of warning (“black box warning”) about the risks of misuse, abuse, addiction, overdose and death, and slowed or difficult breathing that can result from exposure to codeine or hydrocodone.

Another article published in Pediatrics in June of 2017 looked at the risks of over the counter cold and cough remedies for children and found that between 2009 and 2014 there were 3251 reports of adverse events, 60% of which were in children under the age of 4, and which included racing heart, somnolence, hallucinations, gait disturbances and agitation. There were 20 cases of death, most in children under the age of 2 and involving an unsupervised ingestion of diphenhydramine or dextromethorphan.

One of the authors of the first study stated, “Health care providers should never prescribe opioid-containing cough and cold products to children. Ever”. Given the fact that none of these medicines, with or without opioids, works to reduce cough or other cold symptoms I would expand that to say don’t prescribe or recommend them at all, to anyone, ever. Another of my favorites of Dad’s sayings, which he always used when people asked what they should use for a cold: “a handkerchief”.


Ian M. Paul, Kate M. Reynolds & Jody L. Green (2018) Adverse events associated with opioid-containing cough and cold medications in children, Clinical Toxicology, DOI: 10.1080/15563650.2018.1459665

Noah Nesin, MD

Dr. Nesin, Vice President of Medical Affairs for PCHC, is a family doctor with 30 years of experience.

Leave a Reply

Your email address will not be published. Required fields are marked *