What are the recommended doses of over-the-counter medications like Tylenol (acetaminophen) and Robitussin (dextromethorphan) for cold and cough management in adults and children?

Cold and Cough Management: Brand Names and Doses

For children under 4 years: Do NOT use any over-the-counter cough and cold medications—they are ineffective and potentially dangerous. 1, 2

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Children (Pediatric Dosing)

Children Under 4 Years

• NO OTC cough/cold medications - FDA warning due to serious adverse events including death from toxicity 1, 2
• Honey (for children ≥12 months): 2.5-5 mL as needed for cough relief - more effective than diphenhydramine or placebo 1, 3
• Nasal saline irrigation: Safe and effective for nasal congestion 3
• Vapor rub (camphor/menthol/eucalyptus): Topical application for symptomatic relief 4, 3

Children 4-6 Years

• Dextromethorphan (Robitussin, Delsym): 2.5 mL every 12 hours, maximum 5 mL in 24 hours 5
  • Note: Evidence for efficacy is limited; antihistamine/dextromethorphan combinations associated with adverse events 1
• Acetaminophen (Tylenol): 10-15 mg/kg every 4-6 hours, maximum 75 mg/kg/day (not to exceed 3,750 mg/day) 3
• Honey: Continue as first-line for cough 1

Children 6-12 Years

• Dextromethorphan (Robitussin, Delsym): 5 mL every 12 hours, maximum 10 mL in 24 hours 5
• Acetaminophen (Tylenol): 10-15 mg/kg every 4-6 hours, maximum 75 mg/kg/day (not to exceed 3,750 mg/day) 3
• Intranasal ipratropium (Atrovent): For rhinorrhea if prescribed 3

Children ≥12 Years

• Dextromethorphan (Robitussin, Delsym): 10 mL every 12 hours, maximum 20 mL in 24 hours 5
• Acetaminophen (Tylenol): 325-650 mg every 4-6 hours, maximum 3,000 mg/day 3
• Pseudoephedrine (Sudafed): 30-60 mg every 4-6 hours, maximum 240 mg/day for nasal congestion 6

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Adults (≥18 Years)

For Cough

• Dextromethorphan (Robitussin, Delsym): 10 mL every 12 hours, maximum 20 mL in 24 hours 5
  • Limited efficacy for URI-related cough; more effective for chronic bronchitis 1
• Codeine: 7.5-30 mg every 4-6 hours for chronic bronchitis-related cough 1
  • NOT recommended for common cold cough; restricted to adults ≥18 years 1, 7

For Nasal Congestion

• Pseudoephedrine (Sudafed): 60 mg every 4-6 hours or 120 mg extended-release every 12 hours, maximum 240 mg/day 6
  • Produces 6% decrease in subjective symptoms with single dose 6
• Phenylephrine (Sudafed PE): 10 mg every 4 hours, maximum 60 mg/day 6
• Oxymetazoline nasal spray (Afrin): 2-3 sprays per nostril twice daily, maximum 3 days to avoid rebound congestion 6

For Pain/Fever

• Acetaminophen (Tylenol): 325-650 mg every 4-6 hours or 1,000 mg every 6-8 hours, maximum 3,000 mg/day 3
• Naproxen (Aleve): 220-440 mg every 8-12 hours, maximum 660 mg/day 1
  • Strongly recommended by ACCP for common cold symptoms unless contraindicated 1

For Rhinorrhea

• Intranasal ipratropium (Atrovent): 2 sprays (42 mcg) per nostril 3-4 times daily 1, 3
  • Only inhaled anticholinergic recommended for cough suppression 1

Combination Products

• First-generation antihistamine/decongestant combinations (e.g., Actifed: triprolidine 2.5 mg + pseudoephedrine 60 mg): Every 4-6 hours 1
  • Strongly recommended by ACCP; newer nonsedating antihistamines are NOT effective 1
• Avoid other OTC combination products until proven effective in trials 1

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Critical Warnings

Medications to AVOID

• Codeine in children <18 years: Risk of respiratory distress and death 1
• Antihistamines alone in children: Minimal to no efficacy 1
• Albuterol for cough not due to asthma: Ineffective 1
• Zinc preparations: Not recommended; no benefit for cough 1
• Antibiotics: Not effective for viral URI/common cold 1, 4

Common Pitfalls

• Exceeding maximum doses: 8-11% of children receive excessive doses leading to toxicity 2
• Prolonged nasal decongestant use: Limit topical decongestants to 3 days maximum to prevent rebound congestion 6
• Misdiagnosing acute bronchitis: Often overdiagnosed, leading to unnecessary antibiotic prescriptions 1

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Treatment Algorithm

Step 1: Determine patient age

• <4 years: Honey (if ≥12 months), saline irrigation, vapor rub only
• 4-12 years: Consider dextromethorphan with caution; prefer honey
• ≥12 years/adults: Full range of options available

Step 2: Identify primary symptom

• Cough: Honey (children), dextromethorphan (limited benefit), codeine only for chronic bronchitis in adults
• Nasal congestion: Pseudoephedrine or topical decongestants (≤3 days)
• Rhinorrhea: Ipratropium nasal spray or first-generation antihistamine/decongestant
• Pain/fever: Acetaminophen or naproxen

Step 3: Treat underlying cause, not just symptoms 1, 2

• If cough persists >4 weeks, investigate further 2
• If biphasic worsening occurs, consider bacterial sinusitis or pertussis 1