Update on Allergies, Cough & Cold in Children

Nardine Nakhla, PharmD

Adjunct Clinical Assistant Professor @ School of Pharmacy, University of Waterloo

Lecturer & CPD Education Coordinator @ Leslie Dan Faculty of Pharmacy, University of Toronto

nnakhla@uwaterloo.ca OR nardine.nakhla@utoronto.ca

Roger’s Self-Care Symposium 2014

Learning Objectives

After this session, pharmacists will be able to:

1.  Differentiate between upper respiratory tract infections

2.  Examine the pathophysiology of the common cold

3.  Review Health Canada Guidelines for pediatric cough and cold meds

4.  Discuss non-pharmacologic prevention and management

5.  Explore options for pharmacological treatment and natural health product use in children

Disclosures

¤  None to declare

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Question #1

¤  Which symptom is more common in patients with allergic rhinitis than those with the common cold? a.  Congestion

b.  Sore Throat

c.  Pruritus

d.  Fever

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Question #2

¤  Which of the following nonpharmacologic interventions has efficacy to support its use in pediatric colds? a.  Honey

b.  Humidification of air

c.  Increasing fluid consumption

d.  a & b

e.  a, b & c

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Question #3

¤  Which of the following doses of honey is recommended for a 2-year old with with a cough associated with the common cold? a.  2.5mL hs

b.  5mL hs

c.  10mL hs

d.  5mL BID

e.  It’s not recommended for this age group

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Question #4

¤  The approximate acetaminophen dosage that should be recommended for a 4-year-old who weighs 16kg is: a.  80mg

b.  120mg

c.  240mg

d.  325mg

e.  500mg

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Why are we talking about this?

¤  Viral Rhinitis & Allergic Rhinitis ¤  are two of the most common conditions for which patients

seek self-treatment

¤  have overlapping symptoms thus distinguishing between them can be difficult

¤  are symptomatically-managed using OTC products

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“…more than one-half of children younger than 12 years of age use one or more medicinal products in a given week; OTC products, mostly cough and cold medications, account for the majority of medication exposures.”

Vernacchio L, Kelly JP, Kaufman DW, Mitchell AA. Medication use among children 12 years of age in the United States: Results from the Slone Survey.

Pediatrics 2009;124(2):446-54.

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CCM Issues •  Age <2 years

•  Use of medication for sedation

•  Use in a daycare setting

•  Combining ≥2 medications with the same ingredient

•  Product misidentification

•  Use of products intended for adults

Paediatr Child Health. 2011 Nov;16(9):564-9.

Upper Respiratory Tract Infections (URTIs)

¤  Spectrum of acute infections: ¤  May involve the sinuses, pharynx, larynx, trachea, bronchi, nose

¤  Very common in all age groups

¤  Infection may be caused by: ¤  virus, bacteria and fungi

¤  Treatment of viral infection: ¤  symptomatic in most patients ¤  antivirals for high-risk influenza patients

¤  Treatment of bacterial infections: ¤  consultation with a physician

¤  Viral and bacterial infections may be difficult to differentiate

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Etiology of URT Conditions1

¤ Viral Rhinitis: Viral ¤  Influenza: Viral ¤  Sinusitis: Viral, Bacterial, Fungal (rare)

¤  Pharyngitis: Viral (most common), Bacterial ¤ Allergic Rhinitis: no infectious etiology

Recognizing RED FLAGS is vital

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¤  Bacterial Infection suspected: ¤  Presence of fever > 72 hours

¤  Severe, sudden throat pain

¤  Prolonged congestion

¤  Difficulty breathing

¤  Earache (esp. in children)

REFER

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Viral vs. Bacterial Infections1,2

GENERAL URTI’s: EXCLUSIONS FOR SELF- TREATMENT2

q Difficulty breathing, stridor, wheezing, chest pain when breathing, SOB

q Chronic cardiopulmonary disease q Severe throat pain, HA, neck pain,

Facial or maxillary pain q Prolonged nasal congestion with

purulent discharge q Significant reduction in food and fluid

intake q Cough> 3weeks q Odynophagia or Dysphagia q Immunocompromised q Frail patients of advanced age

(usually >65)

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GENERAL URTI’s in CHILDREN: EXCLUSIONS FOR SELF- TREATMENT1

q Symptoms consistent with croup, epiglottitis, or otitis media

q Excessive lethargy or irritability q Skin rash q Cough associated with vomiting q Infants <6 months with fever q Dehydration Signs

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URTI: Approaching the Patient

¤ Patient Assessment:

Determine the patient’s: ¤  Symptoms

¤  Duration ¤  Risk factors for serious disease

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Differential Diagnosis Symptom Viral Rhinitis

(Cold) Allergic Rhinitis

Influenza Sinusitis Pharyngitis

Nasal discharge & congestion

Clear @ 1st à muco-purulent Nasal Congestion common

Abundant; Aqueous & clear Possible Nasal congestion

Clear @ 1st à muco-purulent Nasal Congestion rare

Persistent, purulent rhinorrhea

Rare

Fever Rare, Mild

No Yes, sudden onset(38-40°C)

No Yes

Sore throat Common Mild (dry, scratchy)

No Sometimes No Sudden, Severe Onset

Cough Mild-Mod 1st Dry à productive

Possible via post-nasal drip

Common; Unproductive

Possible via post-nasal drip

Rare

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Symptom Viral Rhinitis (Cold)

Allergic Rhinitis

Influenza Sinusitis Pharyngitis

Headache Rare, via sinus congestion

Via sinus congestion

Yes Via sinus congestion

---------

General Aches & Pain

Mild Earaches, especially in children

Common (myalgia)

Rare Possible

Other Sneezing in the first couple days

Pruritus (palate, nose, eyes) Sneezing, Lacrimation

Fatigue, weakness, chills, nausea, vomiting

Facial tenderness Jaw & tooth pain

-----------

Duration

~5-7 days (25% last 14 days)

As long as exposed to the allergen

10 days Days to weeks

3 days

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Differential Diagnosis

The common cold

VIRAL RHINITIS

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q Very common infectious disease: q Children: 6-8 colds/year q Adults <60: 2-4 colds/year

q Leading cause of work & school absenteeism

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Viral Rhinitis

Heikkinen, T, Jarvinen, A. 2003, Lancet, Vol. 361, pp. 51-59

¤ Viral infection occurring at any time of the year ¤  Infecting Agents: >200 different viruses

¤  Rhinoviruses (30-50%) most common in all age groups ¤  >100 serotypes identified

¤  ñPrevalence during early fall & late spring

¤  Coronaviruses (10-20%) ¤  ñPrevalence during mid-winter & early spring

¤  Other common viruses: ¤  RSV, Adenovirus, Parainfluenza, Enterovirus

Viruses: Modes of Transmission

1.  Self-Inoculation of nasal mucosa or conjunctiva following hand contact w/ viral-laden secretions on:

•  Animate Objects (hands): directly from an infected person

•  Inanimate Objects (doorknobs, phones): indirectly from environmental surfaces

2.  Prolonged contact with airborne droplets produced by coughing, sneezing, talking:

•  Small-particle aerosols lingering in the air •  Direct hit by large-particle aerosols from

an infected person

21 Heikkinen T, Järvinen A. The Lancet. 2003;361(9351):51–59.

Fashner J, et al. Am Fam Physician. 2012;86(2):153–159.

Killer T-Cells Activated & Antibody Production Begins

Bradykinin, PG’s, Histamine, Other Cytokines

Sore Throat, Nasal Congestion, Rhinorhhea, Sneezing, Fever/Chills, Cough

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Incubation Period: 24 to 72 hours The symptoms of the common cold may be due largely to the immune response to infection,

rather than to direct viral damage to the respiratory tract.

Jackson G, et al 1958, Archives of Internal Medicine, Vol. 101, pp. 267-278 Picture adapted from: http://www.mikeschoice.com/reports/common_cold_info.html

Battle Ensues… Cold Virus Wins!

Clinical Presentation & Cold Infection Progression1,2

Throat Discomfort

Nasal congestion &

rhinorrhea

Cough may be present; may persist for 1-2

weeks

Nasal discharge is clear and watery at the beginning & becomes mucopurulent Dry at the beginning then

often becomes productive

Day 1 Day 2 Day 3 Day 4 Day 5

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Self-Limiting Illness- Total Symptom Duration: 7-14 days

Heikkinen T. The Lancet. 2003;361(9351):51–59.

Findings: ¤  Slightly red pharynx w/

evidence of postnasal drainage

¤  Nasal obstruction

¤  Mildly to moderately tender sinuses on palpation

¤  Low-grade fever possible

¤  Rarely >37.8°C (100°F)

¤  Children >>> Adults

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Complications: may cause exacerbations of asthma or COPD and/or can predispose individuals to bacterial complications:

o  sinusitis, pneumonia, bronchitis, otitis media (kids)

Physical Assessment

Type of Cough Clinical Presentation

PRODUCTIVE (wet or “chesty”)

•Expels  secretions from the lower respiratory tract that if retained could impair ventilation and the lungs’ ability to resist infection •Secretions   may be clear (bronchitis), purulent (bacterial infection), discolored (yellow w/ inflammatory disorders) or malodorous (anaerobic bacterial infection)

NON-PRODUCTIVE (dry or “hacking”)

•Serves no useful physiologic purpose; Associated w/ viral RTI, GERD, cardiac disease, some meds, atypical bacterial infections

Handbook of Nonprescription Drugs, 16th Edition CHEST 2006;129:222s-231S

Cough Presentation3

Viral Rhinitis: Goals of Therapy1,2 ¤  PREVENT transmission of cold viruses

¤  Reduce bothersome symptoms ¤  Mainstay of treatment= Symptomatic

¤  Single-entity products preferred (adults) ¤  Antibiotics ineffective

¤  Cochrane review of 4 studies: ¤  No difference in persistence of symptoms for the

common cold or acute purulent rhinitis compared with placebo

¤  Insufficient evidence of benefit to warrant the use of antibiotics for URTI’s in children or adults

¤  Prevent complications ¤  Monitor for worsening and/or additional symptoms

26 Cochrane Database Syst Rev. 2005 Jul 20;(3):CD000247.

GENERAL URTI PREVENTION MEASURES

¤  Routine Handwashing ¤  Proper technique: http://www.cdc.gov/handwashing/

¤  Alcohol-based hand sanitizers after washing hands, or when water is not available ¤  Use as a supplement to regular, effective handwashing ¤  Not effective when hands are visibly soiled! ¤  Efficacious: Ethyl Alcohol 62-95%, Benzalkonium chloride, Salicylic Acid, Pyroglutamic acid, Triclosan

¤  Antiviral Commercial Products ¤  Lysol & Antiviral Tissues

¤  Sneeze & Cough etiquette ¤  into your arm or a tissue (promptly throw away & wash hands)

¤  Avoid touching the nasal mucosa and conjunctiva

¤  Children should avoid sharing beverages or food

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Treating children with CCMs

¤  Current treatment options only target symptom reduction

¤  Lack of evidence for the vast majority of interventions for the management of viral rhinitis

¤  Between January 1995 and May 2008, Health Canada received 164 reports of adverse reactions in children under 12 related to cough and cold products; 105 were considered serious, including five deaths in children under the age of two.

¤  Reported side effects in children using OTC CCM’s include convulsions, increased heart rate, decreased consciousness, abnormal heart rhythms and hallucinations.

¤ Do not use cough/cold products in children under 6 due to efficacy and safety concerns ¤ No evidence for efficacy, reports of rare but

serious side effects (convulsions, increased heart rate, hallucinations, etc.)

¤ Changes in labeling ¤  Ingredients: antihistamines, antitussives,

expectorants, decongestants

¤ Ages 6-11 – limited evidence but dosage provided on packaging (extrapolated from adult dosing)

Health Canada Advisory (2008)

http://www.healthycanadians.gc.ca/recall-alert-rappel-avis/hc-sc/2008/13267a-eng.php?_ga=1.190736739.910427979.1399151566

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Required all Mfg’s

to re-label OTC

cough & cold

meds w/ these AI’s

to indicate

they shouldn’t be used

in children < 6 y/o

Therapeutic Category Active IngredientsAntihistamines in cough and cold medicines

brompheniramine maleatechlorpheniramine maleateclemastine hydrogen fumeratedexbrompheniramine maleatediphenhydramine hydrochloride diphenylpyraline hydrochloridedoxylamine succinatepheniramine maleatephenyltoloxamine citratepromethazine hydrochloridepyrilamine maleatetriprolidine hydrochloride

Antitussives dextromethorphandextromethorphan hydrobromidediphenhydramine hydrochloride

Expectorants guaifenesin (glyceryl guaiacolate)

Decongestants ephedrine hydrochloride/sulphatephenylephrinehydrochloride/sulphatepseudoephedrine hydrochloride/sulphate

Health Canada is requiring manufacturers to relabel over-the-counter cough and cold medicines with certain active ingredients to indicate that they should not be used in

children under 6. Fall 2009

http://www.hc-sc.gc.ca/dhp-mps/medeff/res/cough-toux-eng.php

Health Canada Advisory 2008

Viral Rhinitis: Nonprescription Therapy1,2,4

CPS Practice Point 2011: “Treating cough and cold: Guidance for caregivers of children and youth” http://www.cps.ca/documents/position/treating-cough-cold

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q Decongestants

q Antihistamines

q Antitussives and Protussives

q Local Anesthetics

q Systemic Analgesics

q Natural Health Products

Cochrane Review 2012

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26 Trials (n=4037)

18 in Adults (n=3421)

8 in Children (n=616)

Antitussives (2)

Antihistamine/Decongestant

(2)

Antitussive/Bronchodilator

(1)

Antihistamines (2)

Mucolytic (1)

were no more effective than

placebo in viral-induced cough

Cochrane Database Syst Rev. 2012 Aug 15;8:CD001831.

Antitussives

Cochrane Review of 3 studies:

¤  n=57 ¤  DXM vs. codeine vs. placebo nightly dose: neither drug was

more effective than placebo on day 3

¤  n=50 ¤  DXM vs. placebo TID: no differences in patient-recorded

symptom scores or adverse effects (mild)

¤  n=100 ¤  DXM vs. diphenhydramine vs. placebo nightly dose: DXM no

more effective than other 2 in reducing cough frequency or impact on child or parental sleep

No more effective than placebo for cough

33 Cochrane Database Syst Rev. 2008 Jan 23;(1):CD001831.

Antihistamine + Decongestant Cochrane Review of 2 studies:

¤  n=59 ¤  Brompheniramine + phenylpropanolamine: no more effective

than placebo in reducing number of children coughing 2 hours post dose

¤  Higher proportion of children were reported asleep in active treatment group

¤  n=96 ¤  Brompheniramine/phenylephrine/propanolamine: no

differences among the study groups in the proportion of children considered “better” overall by the parent 48 hours after the initial assessment

No more effective than placebo for cough

34 Cochrane Database Syst Rev. 2008 Jan 23;(1):CD001831.

¤  Cochrane Review 2009: Antihistamines for the common cold ¤  32 papers; n=8930 with common cold ¤  NO evidence of any clinically significant effect in children

regarding general recovery when antihistamines were used as monotherapy

¤  1st generation antihistamines à more side-effects vs. placebo ¤  Antihistamines + decongestants à not effective in children

¤  Cochrane Review 2012: Oral antihistamine-decongestant-analgesic combinations for the common cold ¤  27 trials; n=5117 ¤  General benefit in adults & older children ¤  NO evidence of effectiveness in young children

No more effective than placebo for cough 35

Cochrane Database Syst Rev. 2012 Feb 15;2:CD004976

Cochrane Database Syst Rev. 2009 Oct 7;(4):CD001267

Antihistamines

Expectorants

¤  Limited evidence in acute cough and URTI for any age group

¤  No specific or individual reports of Guaifenesin poisoning

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Echinacea

¤  Cochrane Review 2006: Echinacea for preventing and treating the common cold ¤  16 trials investigating effectiveness of several different Echinacea

preparations ¤  Methodological flaws ¤  No sufficient data to support the effectiveness in children ¤  Use of Echinacea for 8-12 weeks of as a prophylactic measure did

not result in effective prevention of the cold

¤  Cochrane Review 2014: Echinacea for preventing and treating the common cold ¤  24 trials; n=4631

¤  Overall evidence for clinically relevant treatment effects is weak ¤  Trials for preventing colds did not show statistically significant

reductions in illness occurrence

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Cochrane Database Syst Rev. 2006 Jan 25;(1):CD000530.

Cochrane Database Syst Rev. 2014 Feb 20;2:CD000530.

…so what can I recommend? cough and cold symptoms

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¤  Rest

¤  Nasal bulb syringe

¤  Upright positioning

¤  Adequate fluid intake

¤  ñAir humidity

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Viral Rhinitis: Nonpharm Measures1,2

Parents/caregivers should be encouraged to rely primarily on

nonpharmacologic measures for children younger than 6 years old

Paediatr Child Health. 2011 Nov;16(9):564-9.

Nasal irrigation with saline

¤  During acute illness: alleviates sore throat, thins nasal secretions, improves nasal breathing, and can reduce need for nasal decongestants and mucolytics

¤  Study: Efficacy of isotonic nasal wash (seawater) in the treatment and prevention of rhinitis in children ¤  n=401 (age of children studied: 6-10 years)

¤  Dose: 10-30 drops (depending on age) x 7 days

¤  children in the saline group showed faster resolution of some nasal symptoms during acute illness and less frequent reappearance of rhinitis subsequently.

May be effective for the common cold in children

40 Arch Otolaryngol Head Neck Surg. 2008 Jan;134(1):67-74

Topical Antitussives

¤  Vapor Rub Study: ¤  2-5 year olds: 5mL once daily

¤  6-11 year olds: 10mL once daily

¤  When applied to the chest and neck has been shown to improve cough severity and quality of sleep for the child and parents ¤  strong smell that children may not tolerate

¤  may be effective for the common cold in children

41 Pediatrics. 2010 Dec;126(6):1092-9. doi: 10.1542/peds.2010-1601. Epub 2010 Nov 8.

Am Fam Physician. 2012 Jul 15;86(2):153-159.

Zinc

¤  May inhibit viral growth

¤  Mixed evidence ¤  2007 Review:

¤  3 out of 4 studies: no therapeutic effect from zinc lozenge or nasal spray

¤  1 study: positive results from zinc nasal gel ¤  Conclusion: therapeutic effectiveness of zinc has yet to be

established ¤  2003

¤  Reduction of the duration and severity of symptoms of the common cold when administered within 24 hours of the onset of common cold symptoms

¤  “At the present time, the use of zinc in children with cough and cold is not recommended” – CPS Practice Point

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Clin Infect Dis. 2007 Sep 1;45(5):569-74. Epub 2007 Jul 20.

J Am Pharm Assoc (2003). 2004 Sep-Oct;44(5):594-603

Pasteurized Honey

¤  Safe in children > 1 year of age

¤  Demulcent, antioxidant and antimicrobial effects

¤  105 children w/ URTI, nocturnal sx, illness duration ≤7 days ¤  Single bedtime dose of buckwheat honey, honey-flavoured DM

or no treatment ¤  Honey significantly superior to no treatment for cough

frequency; DM no better than no treatment ¤  Parents rated honey highest for symptomatic relief of nocturnal

cough and sleep difficulty due to URTI

¤  Cochrane Review 2012: ¤  Honey may be better than “no treatment” and

diphenhydramine for cough but not better than DXM ¤  No strong evidence for or against the use of honey

43 Paediatr Child Health. 2011 Nov;16(9):564-9.

Arch Pediatr Adolesc Med. 2007 Dec;161(12):1140-6.

Vitamin C

¤ Cochrane Review 2007: Vitamin C for preventing and treating the common cold ¤  30 comparisons; n=11,306 ¤  Reduction in cold duration of >13% among children when

vitamin C given prophylactically ¤  Evidence does not currently support its use in prevention or

treatment of URTIs except in extreme conditions (ex. marathon runners)

¤  No clear recommendation can be found with respect to the dose of vitamin C or whether any interaction with other drugs or adverse events can be anticipated when using it on a regular basis

44 Cochrane Database Syst Rev. 2007 Jul 18;(3):CD000980.

Analgesics/ Antipyretics

¤  Acetaminophen: 10-15mg/kg/dose ¤  www.getreliefresponsibly.ca

¤  Ibuprofen: 5-10mg/kg/dose ¤  When compared with placebo and other treatments in a

recent Cochrane review with nine RCTs, describing 37 comparisons (placebo or other NSAIDs) and more than 1000 patients, NSAIDs did not significantly reduce the total symptom score or duration of the cold, but were found to be beneficial for discomfort or pain caused by the viral illness.

45 Paediatr Child Health. 2011 Nov;16(9):564-9.

Bottom Line CPS Practice Point: Paediatr Child Health. 2011 Nov;16(9):564-9.

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¤  Symptoms gradually disappear after 7 - 10 days ¤  Targeted NonRx therapy for symptom relief usually successful

¤  Symptoms don’t improve or worsen after 14 daysà REFER

¤  Development of S/S of possible complications à REFER

¤  Monitor for this by measuring: temperature, assessing nasal secretions, respirations, facial/neck pain

¤  Note: nasal secretions change from clear to yellow or green during the normal course of the common cold

¤  this discoloration usually does not indicate the presence of secondary bacterial sinus infection unless it fails to resolve after 10 to 14 days

¤  Telephone follow-up in 7-14 days

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Viral Rhinitis: Evaluation of Outcomes1,2

¤  Explain that very few interventions have evidence to support their use ¤  Provide strong clinical messages on:

¤  self-limited nature of the common cold

¤  importance of preventative measures

¤  which treatments are safe and effective and which ones are not

¤  Nonpharmacologic measures may be effective in relieving some of the discomfort of cold symptoms

¤  Screen self-treating patients thoroughly for signs and symptoms of a more serious condition that warrants referral ¤  Offer instructions on when the patient should be evaluated by a

primary care provider

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Viral Rhinitis: Patient Counselling1,2

TO TREAT OR NOT TO TREAT…

“If you treat a cold, it lasts for about seven days, and if you don't treat it, it will last about a week.”

QUESTIONS? Twitter: @NardineN3 Blog: www.facebook.com/selfcarenews

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References

1.  Roy H. Chapter 22: Assessment of Patients with Upper Respiratory Tract Symptoms. Patient Self-Care: Helping your patients make Therapeutic Choices. 2nd Edition. Ottawa, ON: Canadian Pharmacists Association; 2010: 167-170.

2.  Scolaro K. Chapter 11: Disorders Related to Colds and Allergies. Handbook of Nonprescription Drugs: An Interactive Approach to Self-Care. 16th Edition. Washington, DC: American Pharmacists Association; 2009:83–94.

3.  Cough Slides. TLC Consulting, Inc.  Teresa C. German, PharmD, President. Supported by: P&G Health Care. Nov 2009. Other contributors: Ferreri S, Scolaro.

4.  Canadian Pharmacists Association. Compendium of Self-Care Products: The Canadian Reference for Nonprescription Products. 2nd Edition. Ottawa, ON; 2010: 32-53.

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Patient-friendly Resources

¤  http://www.chpcanada.ca/en/blog/things-you-need-know-about-common-cold

¤  http://www.cdc.gov/getsmart/antibiotic-use/URI/colds.html

¤  http://www.hc-sc.gc.ca/hl-vs/iyh-vsv/diseases-maladies/hands-mains-eng.php

¤  http://www.ccohs.ca/oshanswers/diseases/common_cold.html

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