Maxtra Syrup (Dextromethorphan) Should Not Be Used in Infants
Dextromethorphan-containing cough and cold medications are not recommended for infants and should be avoided in this age group due to safety concerns, lack of proven efficacy, and association with serious adverse events including death. 1, 2, 3
Evidence Against Use in Infants
Safety Concerns and Mortality Risk
Fatal outcomes have been documented in infants who received over-the-counter cough and cold medications containing dextromethorphan, with 70% of deaths occurring in children under 2 years of age. 3
A comprehensive safety surveillance program identified 4,202 adverse events related to cough and cold medications in children under 12 years, with 20 deaths (0.6%), predominantly in infants under 2 years. 2
Postmortem toxicology in unexpected infant deaths (ages 17 days to 10 months) revealed evidence of dextromethorphan and other cold medication ingredients, raising significant concern about their role in these fatalities. 3
Guideline Recommendations
The CHEST guidelines explicitly recommend against using over-the-counter cough and cold medicines in children with acute cough, stating they should not be prescribed until proven to make cough less severe or resolve sooner. 1
Honey may offer more relief than dextromethorphan for cough symptoms in children, though this applies to children old enough to safely consume honey (over 12 months). 1
The guidelines specifically recommend avoiding codeine-containing medications due to potential for serious side effects including respiratory distress, and similar caution applies to other antitussives in young children. 1
Common Exposure Patterns
Accidental unsupervised ingestions (67.1%) and medication errors (13.0%) were the most common exposure types leading to adverse events, highlighting the risk even when parents have good intentions. 2
Families who used these medications in infants were often poor, publicly insured, and 50% had limited English proficiency, suggesting educational barriers contribute to inappropriate use. 3
Only 4 of 10 infants who died had received medical care for their illness before death, and only 1 had the medication prescribed by a clinician, indicating widespread self-medication practices. 3
Clinical Pitfalls to Avoid
Do not prescribe or recommend dextromethorphan-containing products for infants under any circumstances, as no therapeutic benefit has been demonstrated in this age group and risks are substantial. 1, 3
Warnings on medications "to consult a clinician" before use are not being followed by parents, so active counseling against use is necessary rather than relying on product labeling. 3
Be aware that liquid pediatric formulations (67.3% of cases) and single-ingredient products (77.5%) were most commonly involved in adverse events, not just combination products. 2