Agony of the Feet

It Grows On You, aka BUNIONS
Looks like A bony lump on the outer edge of your big toe.
Happens when The lowest joint becomes misaligned, causing the end of the bone to jut out. Though pointy heels that squash your toes can make bunions more painful, shoes are not the cause. More crucial factors are the shape of your feet and the way you walk.
How to deal Buy footwear made of stretchy material, such as leather, that will conform to the curves of your foot. Before throwing down your plastic, hold the sole of the shoe against the sole of your foot to make sure the toe box is at least as wide as your tootsies. Using custom insoles, which any podiatrist can provide, may prevent bunions from worsening, but surgery is the only real cure. Still, docs don't recommend it unless the pain is so bad you can't function normally. Most procedures involve shaving down the bone and realigning the toe with a pin or a screw, which leaves you hobbling around for one to two months afterward. Plus, stubborn bunions come back in 10 to 15 percent of cases.
MC Freaky Feet aka HAMMERTOES
Looks like The joint of one of your toes (usually the second piggy) points upward instead of lying flat.
Happens when A bunion, flat or high arches, or too-narrow shoes cause your big toe to butt up against the second toe, putting pressure on the digit and causing it to contract.
How to deal A Budin splint--a flat, foamy pad with an elastic loop that goes under the ball of your foot and wraps around the hammertoe--can reduce pressure and friction from shoes. A podiatrist can also give you cortisone shots to tame the pain. If you've tried those options and are still desperate, surgery offers permanent relief. A small piece of bone on one or both sides of the joint is removed so the toe can uncurl, and a pin is sometimes left in for a few weeks to keep it in place.

Rubbed the wrong way aka CORNS AND CALLUSES
Looks like Raised layers of thick, dead skin. On the tops of your toes they're called corns; on the bottoms or sides of your feet they're known as calluses.
Happens when There's too much pressure or friction on the feet, often due to ill-fitting shoes or a deformity, like a hammertoe.
How to deal Once or twice a week, in the shower, gently rub the area with a pumice stone until the skin begins to turn pink. Follow with a cream designed to soften calloused skin, such as Gordon Laboratories Gormel creme with 20 percent urea ($13 for 2.5 oz, amazon.com). If the layers are really thick, have a podiatrist shave them down during an in-office medical pedicure (because there's a risk of infection, stay away from the nail salon for this). Avoid OTC medicated pads containing salicylic acid, which can burn healthy skin and cause infection.

Hell on heels aka PLANTAR FASCIITIS
Feels like A stabbing or burning pain in your heel that's often worse in the morning.
Happens when The plantar fascia, a band of tissue that runs from the heel to the ball of the foot, becomes inflamed. This can be triggered by the strain of having exceptionally flat or high arches, standing or walking all day long, being overweight, or doing intense physical activities.
How to deal Try OTC arch supports or custom insoles to take stress off the plantar fascia and a topical gel called Biofreeze, also at drugstores, to increase blood flow and ease the ouch. If you're really in agony, ultrasound therapy and shock-wave therapy can speed healing. There's also a new, minimally invasive surgery called an endoscopic plantar fasciotomy, in which a surgeon makes a tiny snip into the plantar fascia to release the tense tissue. However, a study found that up to 25 percent of people who have this surgery continue to experience pain.

In a pinch aka NEUROMA
Feels like Tingling, burning, or numbness in your foot. It may make you feel as if you're walking on a pebble.
Happens when The bones of two toes--usually the third and fourth ones--rub against one another, pinch­ing the nerve in between. Too-narrow shoes, which cram toes together, are often to blame.
How to deal Most experts recommend cortisone injections, to reduce pain, or alcohol, which will destroy a portion of the nerve. If your foot is still killing you despite the shots, surgery can cut out the squashed nerve.

Control Your Cholesterol: Some Helpful Tips

Joanne LaFleur, PharmD, MSPH

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Dr. LaFleur is a research assistant professor in the University of Utah College of Pharmacy Pharmacotherapy Outcomes Research Center within the Department of Pharmacotherapy.

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Has your doctor told you that you have high cholesterol? Cholesterol is a normal component of the human body—our bodies make some, and we get some from the foods we eat. Our cholesterol levels may get out of balance if (1) our body makes too much, or (2) our body does not remove it efficiently. High cholesterol is not a disease in and of itself, but if left unmanaged, it can be a cause of heart disease or stroke.

Your doctor may have talked to you about good cholesterol, bad cholesterol, and cholesterol goals, or some numbers describing low-density lipoprotein (LDL), high-density lipoprotein (HDL), or total cholesterol. All this information may be confusing and overwhelming. With a few simple facts, however, you can navigate your way back to good cholesterol levels.

Health care professionals use many measures of cholesterol. These measures are determined from laboratory tests using a sample of your blood. Table 1 describes the different types of cholesterol measures.

Table 1

Exercise

Exercise is generally recommended to everyone—regardless of cholesterol level—because regular exercise reduces the risk of heart disease, stroke, diabetes, and even some cancers. In addition, exercise can help you lose weight, which may lower your LDL ("bad") cholesterol and triglycerides. Exercise also increases your HDL ("good") cholesterol.

If you do not normally exercise much, begin slowly with shorter durations (10-15 minutes) and lower-intensity exercise (like walking leisurely). As your fitness improves, increase the duration, frequency, and intensity. Set a goal of 30 to 60 minutes of exercise 4 to 6 times per week.

Diet

Some diet changes may help you control your cholesterol by decreasing the amount of new cholesterol you ingest. By avoiding trans fats (foods that have partially hydrogenated oils on the ingredient list) and saturated fats, you can reduce your LDL cholesterol. To avoid saturated fats, reduce the amount of animal products you eat, such as butter, cheese, and red meats. Increasing your intake of fruits, vegetables, and whole grains and taking a daily multivitamin also can help reduce your risk of heart disease.

Medication

If you have high cholesterol, your doctor probably will prescribe medication based on your particular cholesterol profile. For example, he or she may prescribe a fibrate if you have high triglycerides or a statin for a high LDL cholesterol level. He may even prescribe more than one medication if you have more than one measure that is not at goal. Table 2 summarizes information about many medications. If your doctor prescribes a medication, try to understand what it is supposed to do, how you should take it, and what some potential side effects might be. Your pharmacist is a good source of information about medications.

Table 2

Click on image for larger version

If your doctor prescribes medication, he may talk to you about adherence, or the degree to which you take your medicine as prescribed. Many patients stop taking their cholesterol medicines before they benefit from them. Patients stop taking their medicines for many reasons, including forgetfulness, inconvenience, expensive copayments, or disagreeable side effects. Whatever the reasons, if you find it difficult to take your medications, talk to your doctor or pharmacist about ways to overcome the barriers, as improved adherence will help reduce your risk of heart disease.

Summary

High cholesterol is a risk factor for heart disease and stroke, but it is manageable if you take a few simple steps to change your lifestyle. If a prescription is needed, try to be informed about your medications. If you encounter any problems with your medications, ask your pharmacist to help you to address them, instead of stopping them altogether.

Asthma treatment: Do complementary and alternative approaches work?

Many people try complementary and alternative asthma treatments ranging from herbs to yoga. Discover which home remedies for asthma are most likely to work.

By Mayo Clinic staff

Complementary and alternative asthma treatments range from breathing exercises to herbal remedies. There's limited information about whether most of these treatments really work, but many people try them and claim they help. Here's what the evidence says.

Three promising alternative asthma treatments

More research is still needed to determine just how effective they are, but breathing exercises, yoga and physical exercise are a few of the most promising complementary and alternative asthma treatments.

Breathing exercises
Breathing exercises may improve your quality of life, help reduce asthma symptoms and reduce the amount of medication needed to control your asthma. Two breathing exercises that have been studied include:

• The Buteyko breathing technique. Developed in the 1950s, this method was used to treat asthma in the former Soviet Union. In recent years, it has gained popularity elsewhere. This technique teaches you to habitually breathe less. This prevents breathing too much (hyperventilation). The Buteyko technique also includes advice about relaxation and stress reduction, medication use, nutrition and general health.
• The Papworth method. This sequence of relaxation and breathing techniques involves deep belly breathing (called diaphragmatic breathing), nose breathing and matching your breathing to suit whatever activity you're doing. Some evidence suggests this technique significantly reduces asthma symptoms.

While breathing exercises for asthma are gaining recognition and popularity in the United States, few experts are trained to provide instruction. If you decide to try breathing exercises, you may have to rely on instructional videos or books.

Yoga
This gentle form of exercise has been practiced for thousands of years. There are several types of yoga, but all kinds entail doing a series of stretching poses. In addition to providing the benefits of exercise, yoga also incorporates breathing techniques — called pranayama — which may help reduce asthma symptoms. While more studies are needed to determine how helpful yoga is in treating asthma, doing yoga on a regular basis might help relieve stress — and improve your overall fitness and well-being.

Exercise
You can — and should — keep physically active if you have asthma. Staying active helps control your symptoms and helps you stay healthy. Regular exercise strengthens your lungs so that they don't have to work so hard at breathing. Aim for 30 minutes of physical activity on most days. If you've been inactive, start slowly and gradually increase your activity over time. And, you don't have to do your daily exercise all at once. Doing something that gets your blood pumping and gets you breathing harder for a few short periods — such as 10 or 15 minutes at a time — works too.

Keep in mind that exercising in cold weather may trigger symptoms. If you do exercise in cold temperatures, wear a face mask to warm the air you breathe. And don't exercise in temperatures below zero. Activities such as golf, walking and swimming are less likely to trigger attacks, but be sure to discuss any exercise program with your doctor.

Complementary and alternative medicine

While a number of people try them, evidence is still unclear whether any of the following treatments really work for asthma.

Acupuncture
Acupuncture involves the insertion of thin needles to various depths at strategic points on your body. Acupuncture originated in China thousands of years ago, but over the past two decades its popularity has grown significantly in other parts of the world. While some evidence suggests that asthma symptoms improve with acupuncture treatment, there's still not enough solid evidence to be certain it helps.

Relaxation therapy
Relaxation therapy techniques include meditation, biofeedback, hypnosis and progressive muscle relaxation. Although these techniques seem to reduce stress and promote well-being, it's still unclear exactly what benefits relaxation therapy techniques provide for asthma. Initial research does show that muscle relaxation techniques may improve lung function.

Homeopathy
Homeopathy aims to stimulate the body's self-healing response using very small doses of substances that cause symptoms. In the case of asthma, homeopathic remedies are made from substances that generally trigger an asthmatic reaction, such as pollen or weeds. There's still not enough clear evidence to determine if homeopathy helps treat asthma. The substances that trigger symptoms are used in such minute amounts they are unlikely to cause a reaction. Even so, most asthma experts discourage homeopathic treatment.

Massage and chiropractic treatment
Although some claim that these treatments help, there's no solid evidence that physical manipulation of the spine or muscles, such as massage therapy or chiropractic treatments, helps with asthma symptoms.

Muscle training
This technique helps strengthen the lung muscles with a series of breathing exercises using a special, hand-held breathing apparatus. This type of lung training is sometimes used for other lung diseases such as chronic obstructive pulmonary disease (COPD), and to strengthen the lungs after certain types of surgery. There still isn't sufficient evidence to verify whether this technique helps with asthma.

Herbal remedies
Herbal remedies including butterbur, ginkgo extract and dried ivy have been tried to help with asthma symptoms. But studies are unclear about the benefit of these or other herbal treatments for asthma. Herbal remedies can cause unwanted side effects and interact with prescription medications — and they may not contain consistent doses and may contain harmful substances. Always talk to your doctor before trying any herbal remedy.

Consider the evidence and safety

In most cases, more well-designed studies are needed to make a clear judgment about which CAM therapies for asthma are likely to help. But, keep in mind that lack of solid evidence doesn't necessarily mean these treatments don't work. Although they haven't been rigorously tested in a way that proves they're effective, most haven't been proved ineffective either — they simply haven't been investigated thoroughly enough to make a judgment. While most of these treatments are still not proved, the good news is that it's generally safe to try them along with regular asthma treatment — with the exception of certain herbal supplements, which can be dangerous for some people.

If you do decide to try any complementary or alternative treatment for asthma, be sure to first talk to your doctor about it — and continue your regular treatment. Though some of these treatments may help, when it comes to controlling asthma, alternative treatment is never a substitute for prescribed medications and advice from your doctor.

AS00032

Oct. 4, 2007

Asthma inhalers: Which one's right for you?

Inhalers allow people with asthma to lead active lives without fear of an attack. Here's a rundown of inhaler types, with tips on proper use.

By Mayo Clinic staff

Inhalers have transformed asthma treatment. They enable children and adults with asthma to deliver medicine directly to their lungs nearly anytime and anywhere. A variety of inhalers are available to help relieve or control asthma symptoms.

Types of inhalers

Inhalers are hand-held portable devices that deliver medication directly to the lungs. A variety of inhalers exist, but they basically fall into two categories:

Metered dose inhalers
These inhalers use a chemical propellant to force a measured dose of medication out of the inhaler. They consist of a pressurized canister containing medication, a mouthpiece and a metering valve that dispenses the correct dose of medication. The medication is released either by squeezing the canister or by inhaling. You may find it easier to use a hand-actuated inhaler with a spacer — a short tube that attaches to the inhaler. Using a hand-actuated inhaler to release the medication into the chamber gives you time to inhale more slowly. It decreases the amount of medicine that's deposited on the back of your throat and increases the amount that ultimately reaches your lungs.

Some metered dose inhalers have counters so that you know how many doses remain. If there is no counter, you have to track of the number of doses you've used so that you know when the inhaler is out of medication.

The chemical propellant in metered dose inhalers has traditionally been a chlorofluorocarbon (CFC). But after an international agreement to ban CFCs because they damage the ozone layer, other propellants such as hydrofluoroalkane (HFA) are now used instead. The dose of medication released by an HFA inhaler may feel softer and warmer than the dose released by a CFC inhaler. If you're used to a CFC inhaler, it may not seem like a complete dose — even though the medication is reaching your lungs.

Dry powder inhalers
These inhalers don't use a chemical propellant to push the medication out of the inhaler. Instead, the medication is released by breathing in more quickly than you would with a traditional metered dose inhaler.

Some people find dry powder inhalers easier to use than the conventional pressurized metered dose inhalers because hand-lung coordination isn't required. Some models require operating a cocking device that requires dexterity. Available types include a dry powder tube inhaler, a powder disk inhaler and a single-dose dry powder disk inhaler. Spacers shouldn't be used with dry powder inhalers.

Comparing inhaler types
Choosing the right kind of inhaler for you depends on several factors, such as your hand-breath coordination, your dexterity, whether you can take a deep, fast breath, and what types of medication you need. The chart below can help you understand the pros and cons of each type. Work with your doctor to find the best inhaler for your needs.

Inhaler features

Metered dose inhaler	Metered dose inhaler with a spacer	Dry powder inhaler
Portable and convenient	Less portable and convenient, more complex and more expensive than a metered dose inhaler without a spacer	Portable and convenient
Doesn't require a deep, fast breath	Doesn't require a deep, fast breath	Requires a deep, fast breath
Accidental exhalation before activation won't disrupt medication	Accidental exhalation before activation won't disrupt medication	Accidental exhalation before activation will blow away medication
Hand-actuated models without a spacer require hand-breath coordination	Hand-breath coordination is not critical	Hand-breath coordination is not necessary
Can result in large amounts of medication on the back of your throat and tongue	Less medication settles on the back of your throat and tongue	Can result in large amounts of medication on the back of your throat and tongue
Minimal or no maintenance required	Spacer requires periodic cleaning with soap and water	Minimal or no maintenance required
Some models require you to keep track of how many doses remain	Some models require you to keep track of how many doses remain	It is clear when the device is out of medication
Requires shaking and priming	Requires shaking and priming, correct use of spacer	Single-dose models require loading capsules for each use
Humidity does not affect medication	Humidity does not affect medication	High humidity can cause powdered medication to clump

Medications delivered through inhalers

Inhalers are used to deliver a variety of asthma medications — some that assist with long-term control and others that provide quick relief of symptoms. Some medications may only be available in certain inhaler types. Inhaled asthma medications include:

• Short-acting bronchodilators. These medications, including albuterol (Proventil, Ventolin) and pirbuterol (Maxair), provide immediate relief of asthma symptoms.
• Long-acting bronchodilators. These medications relieve asthma symptoms for longer periods of time. They include salmeterol (Serevent) and formoterol (Foradil).
• Corticosteroids. Used long term to prevent asthma attacks, these medications include beclomethasone dipropionate (Qvar), fluticasone (Flovent), budesonide (Pulmicort), triamcinolone acetonide (Azmacort) and flunisolide (Aerobid).
• Cromolyn or nedocromil. These nonsteroidal medications are used long term to prevent inflammation.
• Corticosteroid plus long-acting bronchodilator. This medication combines a corticosteroid and a long-acting bronchodilator (Advair, Symbicort).

Inhalers may come with slightly different instructions. Follow those instructions carefully and ask your doctor for a demonstration.

The importance of using inhalers properly

It's important that you use your inhaler correctly so that the medication reaches your lungs. Carefully follow the instructions. And ask a doctor, nurse or pharmacist for a demonstration. Use the inhaler in front of this person and ask for feedback. Then practice at home in front of a mirror.

If you're unable to use an inhaler, a nebulizer may be an option. Nebulizers are designed for those who can't use an inhaler, such as infants, young children and those who are seriously ill. The device works by converting medication into a mist and delivering it through a mask that you wear over your nose and mouth.

Using an inhaler is just one part of your asthma treatment plan, which may also include checking your lung function with a peak flow meter, eliminating asthma triggers and exercising. But knowing what types of inhalers are available and how to use them can help you better manage your asthma and get the most from your treatment.

HQ01081

Aug. 17, 2007

Recommendations for the Use of OTC Cough and Cold Medications in Children

Antihistamines

Antihistamines are reversible H₁-receptor antagonists that block histamine activity in the respiratory tract, gastrointestinal (GI) tract, and blood vessels. They may help prevent and treat nasal and ocular itching, rhinorrhea, and sneezing associated with the common cold, but they have not been proven to prevent colds, cure them, or shorten the course. Side effects of antihistamines include drowsiness, nervousness, insomnia, dry mouth, and dizziness. OTC cold and allergy formulas for children contain first- or second-generation antihistamines. There is no FDA-approved dosing of antihistamines for colds; however, dosing for allergic rhinitis is given. The two classes differ mainly in their sedative effects, with first-generation antihistamines causing more sedation.^3-6

First-generation antihistamines include chlorpheniramine, diphenhydramine, and brompheniramine. Appropriate dosing of chlorpheniramine in children aged 2 to 6 years is 0.35 mg/kg/day divided every four to six hours, with a maximum daily dose (MDD) of 6 mg. Recommended diphenhydramine dosing in children aged 2 to 6 years is 5 mg/kg/day divided six hours as needed, with an MDD of 300 mg. Diphenhydramine should not be used in neonates owing to possible central nervous system effects. Dosing of brompheniramine in patients aged 2 to 6 years is 1 mg every four to six hours.² Brompheniramine is not available OTC as a single-active-ingredient product, but it is found in combination with other active ingredients in pediatric cough and cold medications.

Second-generation antihistamines available OTC include cetirizine and loratadine. Appropriate cetirizine dosing in children is as follows: age 6 to 12 months, 2.5 mg/day; age 12 to 23 months, initial dosing 2.5 mg/day (may be increased to 2.5 mg twice/day); age 2 to 5 years, initial dosing 2.5 mg/day (may be increased to 5 mg/day in single or divided doses). The usual dose of loratadine for children aged 2 to 5 years is 5 mg once/day.²

Antihistamines should not be used to sedate children, and manufacturers of certain antihistamine products are making voluntary labeling changes that warn parents not to use the product with the intention of making a child sleepy.¹ Parents should avoid using antihistamines in children with glaucoma, breathing disorders, liver disease, or seizure disorders unless directed otherwise by their primary health care provider.^3-6

Decongestants

Nasal decongestants are sympathomimetic amines that exert their vasoconstrictive action by affecting sympathetic tone in the nasal mucosa. Decongestants decrease enlarged blood vessels and alleviate mucosal edema by acting on adrenergic receptors.^5,7,8 Phenylephrine stimulates alpha-1 receptors, whereas oxymetazoline, xylometazoline, and naphazoline stimulate alpha-2 receptors.⁸

Pseudoephedrine exerts its action by having both a direct and an indirect effect on adrenergic activity. Like phenylephrine and the imidazoline derivatives, pseudoephedrine stimulates alpha receptors but also indirectly causes the release of norepinephrine from its storage sites.^7,8

Systemic and nasal decongestants are available OTC. Systemic nasal decongestants are indicated for temporary relief of nasal congestion, to promote nasal or sinus drainage, and for cough caused by postnasal drip. Topical nasal decongestants are indicated for the symptomatic relief of both nasal and nasopharyngeal mucosal congestion.^5,7

Side effects from decongestants are more likely to occur in children than in adults. Effects include elevated blood pressure, tachycardia, palpitations, arrhythmia, restlessness, insomnia, anxiety, tremors, psychological disturbances, and hypersensitivity reactions. Because they are minimally absorbed, topical decongestants have systemic side effects that are milder and occur less frequently compared with systemic dosage forms. Topical use may cause burning, stinging, sneezing, or local irritation. The use of topical decongestants should be limited to three days, since prolonged use has been associated with tachyphylaxis, rebound nasal mucosa edema, and rebound nasal congestion.^5,7,8

The recommended dosing for phenylephrine nasal drops is 1 to 2 drops of 0.16% solution in each nostril every three hours as needed in infants older than 6 months; in children aged under 6 years, the dosing is 2 to 3 drops of 0.125% solution in each nostril every four hours as needed.² Appropriate dosing of oral phenylephrine in children aged 2 to 6 years is 2.5 mg every four hours or 3.75 mg every six hours, with an MDD of 15 mg.^2,9 Pseudoephedrine in children aged under 12 years is dosed at 4 mg/kg/day divided every six hours as needed with an MDD of 60 mg.^2,9

Expectorants

Guaifenesin is the only nonprescription expectorant available for use in children. It is an oral mucolytic that helps loosen phlegm and bronchial secretions by increasing respiratory-tract secretions, which leads to a more productive cough and better airway clearance.⁶ If the cough lasts for more than one week, recurs, or is accompanied by a fever, rash, or persistent headache, consultation with a primary health care provider is recommended. Adverse effects associated with guaifenesin include nausea, vomiting, dizziness, drowsiness, headache, and rash.

Guaifenesin should be taken with a full glass of water, and adequate hydration during use should be maintained. The extended-release tablets should not be chewed or crushed; therefore, if the patient cannot swallow the tablet, a different dosage form--such as syrup, solution, liquid, or minimelt (oral granule)--should be used. The most effective way to administer the oral granules is to place them on the tongue and swallow them without chewing; they may have an unpleasant taste if chewed. Appropriate dosing for children aged up to 6 years is as follows: age under 2 years, individualized dose (common dosing = 25-50 mg every four hours, with an MDD of 300 mg); age 2 to 6 years, 50 to 100 mg every four hours, with an MDD of 600 mg.^4-6

Antitussives

Codeine, although not available OTC in all states, is the gold-standard antitussive. Nonprescription antitussives that are available OTC to treat cough are dextromethorphan and diphenhydramine.¹⁰ Codeine produces cough suppression by acting centrally on the cough center located in the medulla portion of the brainstem. When used at antitussive doses, codeine should not exhibit addictive properties.¹⁰ Dextromethorphan, the d-isomer of codeine, exerts its pharmacologic action in the same way as codeine; however, it lacks analgesic and addictive properties when used at recommended doses.^4,5 In children, the recommended dose of both dextromethorphan and codeine is 1 mg/kg/day divided into four doses, with an MDD of 30 mg for children aged 2 to 5 years.^2,11 Recommended dosing for diphenhydramine, a first-generation antihistamine, in children aged less than 6 years is 5 mg/kg/day divided every six hours, with an MDD of 300 mg.²

Side effects of codeine include lightheadedness, dizziness, sedation, GI effects, and sweating. The most common effects resulting from an overdose are respiratory depression and a decreased level of alertness or consciousness. It has been reported that codeine is unlikely to produce significant side effects in children given less than 2 mg/kg; however, somnolence, ataxia, miosis, vomiting, rash, facial swelling, and itching have been reported in children receiving codeine doses of 3 to 5 mg/kg/day. Side effects of dextromethorphan include drowsiness, dizziness, nausea, GI upset, and abdominal discomfort.⁴ Dextromethorphan may cause behavioral disturbances and respiratory depression when overdosage occurs.

Insufficient evidence exists to support the use of codeine or dextromethorphan for antitussive purposes in the pediatric population.¹¹ Pharmacists should counsel parents about the lack of data supporting the use of these drugs for antitussive purposes as well as the potential risks associated with their use. Additionally, evidence suggests that second-generation nonsedating antihistamines such as loratadine are ineffective for lessening cough associated with the common cold, and therefore should not be used.¹²

Combination Products

Many nonprescription cough and cold formulations contain more than one active ingredient to treat two or more simultaneous symptoms. It is important to remember that combination cough and cold medications should be used only if the corresponding symptom is present and that combination products should not be given in addition to a different nonprescription product with the same active ingredient.

Nonprescription cough and cold formulations are available in the following combinations: antihistamine/decongestant, antihistamine/antitussive, antitussive/expectorant, decongestant/expectorant, antihistamine/antitussive/decongestant, and antitussive/decongestant/expectorant.⁵ In addition, some multisymptom products contain antipyretics and analgesics such as acetaminophen and ibuprofen. Weight-based dosing of oral acetaminophen in children is recommended at 10 to 15 mg/kg/dose every four to six hours as needed; daily dosing should not exceed 90 mg. Nonprescription ibuprofen dosing for children is 5 to 10 mg/kg/dose every six to eight hours, with an MDD of 40 mg/kg.²

Voluntary and Regulatory Changes

The safety of OTC cough and cold preparations in the pediatric population is of great concern owing to reports of severe adverse reactions and deaths in infants and children. In October 2007, the FDA's advisory committees on Nonprescription Drugs and Pediatrics met to discuss the safety and efficacy of nonprescription cough and cold medications in children. Ten days prior to the meeting, a voluntary withdrawal of 14 nonprescription infant cough and cold medications was announced by the Consumer Healthcare Products Association (CHPA) on behalf of the products' manufacturers. Manufacturers recalled these products even though they believed that they were safe. Cases of misuse leading to overdose of infants less than 2 years of age had been reported. The advisory committees concluded that evidence from pediatric studies was insufficient to prove the efficacy of cold and cough medications in children; they voted 13 to 9 to recommend that cough and cold products no longer be used in children under 6 years of age.^13,14

The FDA issued a public health advisory in January 2008 recommending that OTC cough and cold medications not be used in children under 2 years of age because of the risk of serious, life-threatening adverse events. Additionally, the FDA agreed to the manufacturers' request to change the product labeling to warn parents not to use antihistamine products to sedate children.^13,14

In 2008, the FDA held two public meetings to gather more information about the regulatory process for pediatric cough and cold medicines and about scientific testing in children. On October 8, 2008, the FDA issued a statement supporting the CHPA's announcement that manufacturers of nonprescription OTC cough and cold medicines for children were voluntarily modifying package labeling to state, "Do not use in children under 4 years of age."¹⁵

In addition to product-labeling changes, new child-resistant packaging and measuring devices for the products are being introduced. The manufacturers have been transitioning this new labeling and packaging throughout the 2008-2009 cough and cold season.¹

Complementary and Alternative Therapies

Alternative cough and cold therapies such as increased fluid intake, room humidifiers, nasal dilator strips, nasal aspiration or irrigation, and vitamin C can be used alone or in combination with an OTC cough and cold medication. Increased fluid intake helps prevent dehydration in a child suffering from a cough or cold. Room humidifiers provide relief from congestion by moistening the air.¹⁶ Warm-mist humidifiers work by boiling water in a reservoir, thereby posing a potential burn risk; for that reason, cool-mist humidifiers are generally recommended. Because bacteria thrive in moist settings, parents should be encouraged to empty water from the humidifier and wipe all surfaces dry on a daily basis.¹⁷

Nasal dilator strips are adhesive bands placed on the nose that dilate the nasal air passages or stiffen the nasal wall, leading to increased airflow and thus relieving nasal congestion.^18,19 Nasal dilator strips with or without added menthol are FDA-approved for use in children aged 5 years or older. Latex allergy is a potential concern with this product.¹⁸

Cleansing of the nasal passages with a bulb syringe and nasal irrigation with saline drops are two options for treating small children with congestion. Aspiration with a bulb syringe clears mucus from the nasal passages; 0.65% sodium chloride drops and sprays soothe irritated mucus membranes and rehydrate dried secretions for easier removal from the nasal passages.^7,18

Supplementation with vitamin C may decrease the duration of the common cold in children. A 2004 Cochrane systematic review suggests that, in children, doses of 0.2 g to 2 g vitamin C are beneficial for reducing a cold's duration. Studies have shown that children have a greater decrease in cold duration than adults, and that higher doses confer a greater benefit than lower doses. Studies evaluating 0.2 to 0.75 g/day vitamin C reported a 7% reduction in cold duration compared with an 18% reduction in studies evaluating 1 g/day.²⁰ Children given 2 g/day demonstrated a median decrease in cold duration of 26%, versus a 6% median decrease in adults receiving 1 g/day.²¹ At doses greater than 1 g, side effects including nausea, vomiting, increased iron absorption, and diarrhea may occur.⁵

Conclusion

Pharmacists are accessible members of the health care team and are often consulted by parents or guardians regarding selection of appropriate nonprescription cough and cold products for their children. The parent or guardian should be counseled to carefully follow certain guidelines for usage (see sidebar) when an OTC cough and cold medication is being considered for use in children.^22,23

3/18/2009

US Pharm. 2009;34(3):33-35.