Diphenhydramine and Chlorpheniramine Should NOT Be Used for Cough in Children
Do not use diphenhydramine, chlorpheniramine, or any over-the-counter cough and cold medications in children for cough treatment, as they provide no benefit and carry significant risks of morbidity and mortality. 1, 2
Why These Medications Are Contraindicated
Lack of Efficacy
- Antihistamines including diphenhydramine and chlorpheniramine have minimal to no efficacy for cough relief in children and are no more effective than placebo 2, 3
- Central cough suppressants and antihistamines have limited efficacy in children with cough due to upper respiratory infections 1
- There is no scientific evidence to justify the use of over-the-counter antihistamines for cough in children 3
Significant Safety Concerns
- The American Academy of Pediatrics explicitly advises against all OTC cough and cold medicines in children under 2 years due to lack of efficacy and risk of significant morbidity and mortality 2
- Antihistamines were associated with 69 reported fatalities in children under 6 years between 1969-2006 2
- The American College of Chest Physicians provides a Grade D recommendation (good level of evidence, no benefit) explicitly stating that cough suppressants should not be used in pediatric patients 1
- Over-the-counter cough medications place young children at risk for potential side effects and adverse reactions 4
Specific Evidence on Chlorpheniramine-Containing Products
- A comprehensive benefit-risk review of hydrocodone/chlorpheniramine found no robust efficacy data for relief of cough in patients aged 6 to < 18 years 5
- This evidence contributed to the FDA's decision that such medications should no longer be indicated for treatment of cough in patients < 18 years 5
What TO Use Instead
For Children Over 1 Year
- Honey is the only recommended treatment for acute cough in children over 1 year of age, providing more relief than diphenhydramine, placebo, or no treatment 6, 2
For Children Under 1 Year and All Ages
- Supportive care and watchful waiting are appropriate for most cases of acute cough, as they are typically self-limiting viral infections 2, 4
- Eliminate tobacco smoke exposure and other environmental pollutants 1, 2
- Address parental expectations through education about the natural course of viral illness 1, 2
When to Consider Alternative Diagnoses
Chronic Cough (>4 Weeks Duration)
- Requires careful evaluation including chest radiograph and spirometry if age-appropriate 1, 6
- Consider protracted bacterial bronchitis if wet/productive cough persists >4 weeks: treat with 2-week course of antibiotics 6
- Consider asthma only if documented wheeze on examination, exercise intolerance, nocturnal symptoms, or clear risk factors are present 6
Critical Pitfall to Avoid
- Do not use empirical treatment approaches (including antihistamines for presumed allergic cough) unless specific clinical findings support a particular diagnosis 1, 6
- Any medication trial should be for a defined, limited duration (2-4 weeks) to confirm or refute the diagnosis, then discontinued if no response 1, 6