Benzonatate (Tessalon Perles) Use in 14-Year-Olds
Yes, benzonatate is FDA-approved and appropriate for a 14-year-old at a dose of 100-200 mg three times daily as needed for cough, with a maximum of 600 mg daily in three divided doses. 1
FDA-Approved Dosing
- For children over 10 years of age and adults: The standard dose is one 100 mg or 200 mg capsule three times daily as needed for cough 1
- Maximum daily dose: 600 mg divided into three doses if necessary to control cough 1
- Critical administration requirement: Capsules must be swallowed whole and never broken, chewed, dissolved, cut, or crushed 1
Critical Safety Warnings
The most important safety consideration is proper capsule administration. Benzonatate has local anesthetic properties similar to tetracaine, and if the capsule is chewed or dissolved in the mouth, it can cause rapid oropharyngeal anesthesia, choking risk, and systemic absorption leading to life-threatening toxicity 2, 3.
Overdose Risks in Adolescents
- Rapid onset of toxicity: Severe symptoms including seizures, cardiac arrest, coma, and respiratory arrest can occur within 15 minutes of overdose 2
- Documented adolescent cases: A 13-year-old developed coma, seizures, hypotension, prolonged QT interval, and severe metabolic acidosis after overdose 3
- Cardiac complications: A 14-year-old experienced torsades de pointes and cardiac arrest after ingesting 14 capsules (2,800 mg total) 4
- Permanent neurological damage: A 17-year-old developed residual blindness after cardiac arrest from benzonatate overdose 5
Intentional vs. Unintentional Exposures
- Intentional exposures carry significantly higher risk: 22% of intentional exposures resulted in serious adverse effects (seizures, ECG changes, coma, or death) compared to 0.7% of unintentional exposures 6
- Two deaths occurred over a 20-year period: Both were intentional exposures in the poison center database 6
- Adolescents are at particular risk for intentional ingestion: Given the age group's vulnerability to suicidal ideation, careful assessment and counseling are essential 3, 4, 5
Prescribing Considerations for This Age Group
Before prescribing to a 14-year-old, assess:
- Mental health status: Screen for depression, suicidal ideation, or history of self-harm given the documented cases of intentional overdose in teenagers 3, 4, 5
- Household safety: Ensure secure storage away from younger siblings, as fatal ingestions have occurred in children under 10 years 2
- Alternative therapies first: Consider whether non-pharmacologic measures or safer alternatives have been adequately tried, as guidelines suggest avoiding over-the-counter cough medications in children when possible 7
Patient and Family Education Requirements
Provide explicit counseling on:
- Swallow whole only: Emphasize that chewing, crushing, or dissolving the capsule can cause immediate numbness of the mouth and throat, choking, and potentially fatal toxicity 1, 2
- Secure storage: Keep in original child-resistant container, stored out of reach of younger children 2
- Signs of overdose: Seizures, confusion, irregular heartbeat, difficulty breathing, or loss of consciousness require immediate emergency care 2, 3
- Exact dosing: Do not exceed prescribed dose; taking multiple capsules at once has caused cardiac arrest in teenagers 4
- Immediate disposal: Dispose of unused medication properly when cough resolves 2
Common Pitfalls to Avoid
- Do not assume benzonatate is safer than codeine: While codeine-containing medications should be avoided in children due to respiratory risks 7, benzonatate carries its own serious overdose potential 2, 3, 4
- Do not prescribe large quantities: Limit initial prescription to minimize overdose risk, particularly in adolescents 6, 5
- Do not overlook mental health screening: The rapid lethality of benzonatate overdose makes it particularly dangerous for at-risk adolescents 3, 4, 5