A spoonful of rethinking: India shifts approach to children’s cough syrups

The Union Health Ministry has sent advisories to doctors seeking rational prescription of cough syrups for children in cases where they have a true medical need.

For long, parents have instinctively offered a spoon of syrup to children suffering from coughs. That is quickly changing. In India, there has been a noticeable shift in the approach doctors have been taking while prescribing cough syrups to children, because of safety concerns and updated guidance around such medication.

A wake-up call 

Recent incidents of children dying after consuming contaminated cough syrups have reopened the debate about safety. Investigators found harmful substances in unacceptable amounts, highlighting a failure of quality control in medicines. The loss of these children led to regulators imposing more oversight of cough syrups and some states mandating a prescription before purchase, especially for infants and young children.

The Union Health Ministry also sent advisories to doctors seeking rational prescription of cough syrups for children in cases where they have a true medical need. The advisory also reminded states that most coughs are self-limiting, even if viral. This has shaped expectations of pediatricians for one of the most common symptom complexes in children.

Why doctors are rethinking cough syrups

- Paediatric coughs are most often caused by viral infections, which typically improve within 7–10 days without the need for medication.
- Cough syrups do not treat the underlying infection; they only temporarily suppress symptoms.
- Some ingredients can cause side effects such as drowsiness, vomiting or, in rare cases, breathing problems — especially in children under 2 years.
- Overuse or combining multiple cold medications increases the risk of accidental overdosing.
- Due to these considerations, the national and international guidance now recommends against routinely using cough syrups in young children. The Central Drugs Standard Control Organization (CDSCO) and the expert consensus statement clearly indicate that fixed-dose combinations should be avoided in children under 4 years of age.

It has also recommended physician discretion in deciding to use fixed-dose combinations for children.

When doctors avoid cough syrups

- In children aged 2 or younger, risks outweighs benefits.
- In mild, dry, short coughs due to viral infections, where patients are improving.
- In night time coughs from nasal drip or allergies, home remedies are actually more helpful.
- Paediatricians rely on supportive care in these conditions, which provides patients with equal or greater relief compared to medication.

When doctors prescribe cough syrups 

There are instances where cough syrups help, but these are the exception, not the rule.
- Ongoing coughs that dry out the lungs and interrupt sleep after serious causes are excluded.
- Coughs associated with allergies or asthma – there are medications to treat these conditions. Inhaled medications are the first choice in children with asthma, both for relief during acute episodes and for ensuring there’s no recurrence of symptoms.
- If cough is due to a bacterial infection, antibiotics are the primary intervention and cough syrup may also be given for a short duration to relieve symptoms.
- Coughs that are “wet” but have thick secretions where an expectorant may help clear thick secretions.
- Even in such situations, the dosing is always calculated and provided based on the child’s age and weight. Parents are counselled on how long to give the cough medication and not to self-medicate if another episode occurs as each time the cause maybe different.

(The author is a senior consultant - general pediatrics & pediatric rheumatology.)