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Chapter 2 Index
A. Evaluation by system:
1. General
2. HEENT 3.
Cardiopulmonary
--Heart Murmurs: When to Refer
--How to Feed Infants with Heart Disease
--Syncope in the Pediatric Age-Group
--Asthma: Classification and Management
--Asthma Medication
--Exercise Induced Asthma (EIA)
--Home Monitoring: The Role of the Pediatrician
--Bronchiolitis
--RSV – Incidence and Prevention: 2002 |
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Should Codeine, Dextromethorphan or Hydrocodone be Prescribed?
AAP Committee on Drugs, Pediatrics June 1997
Introduction: Pediatricians often feel that they need to
prescribe something when a patient comes to the office. Of course, the
primary cause of cough - if present - needs to be identified and treated: eg
allergy, GE Reflux, asthma, irritants such as cigarette smoke, dust and wood
heat. Even if one of these etiologies is found, codeine, dextromethorphan,
hydrocodone are often prescribed to give symptomatic treatment to children.
What will you recommend when you are in private practice?
1. Codeine
- Mechanism of action: suppress artificially and disease-related cough
through CNS action
- Dosage usually used: 1 mg/kg/day in 4 divided doses up to 60 mg/day.
- Side Effects: respiratory depression and obtundation; can be
addictive.
- < 2 mg/kg/day: unlikely to have any side effects
- 3-5 mg/kg/day: somnolence, ataxia, miosis, vomiting, rash, facial
swelling, itching
- > 5 mg/kg/day: 3% require mechanical ventilation; 2 deaths.
- Interactions with other medications: If given with Acetaminophen,
increased toxicity:
- Hepatic glucuronidation pathway incompletely developed in infants
putting infants at increased risk, more if given with other meds
metabolized in the liver.
- Evidence of effectiveness: shown to definitely work in the chronic
cough of adults; a linear relationship between the dose and the frequency
of chronic cough. There is no study that shows that codeine is effective
in suppressing cough in children: Ref: Taylor: JPeds 93;122:799-802.
Controlled study: same as placebo.
2. Dextromethorphan
- Mechanism of action: same as codeine; in adults’ works through CNS
action to elevate the threshold for coughing.
- Dosage used: also 1 mg/kg/day in 3 to 4 divided doses.
- Side Effects: behavioral disturbances including respiratory depression
- Evidence of effectiveness: same study of Taylor: no difference from
placebo.
3. Hydrocodone and hydromorphone
- More addictive than codeine and should not be used. Elixir contains
25% alcohol.
4. Combination Medications: antihistamines, decongestants,
expectorants, and antipyretics and codeine or dextromethorphan.
- Problem: these medications are potentially harmful particularly in
children less than 6 mos of age. Immature hepatic enzyme systems make side
effects from decongestants more likely: irritability, restlessness,
lethargy, hallucination, hypertension, and dystonia.
- Dosage: never worked out well so that dosages extrapolated from adult
data.
Conclusions of AAP Committee on Drugs about cough medications in
children:
- No studies support efficacy and safety of narcotics. No clear-cut
indications in children.
- Cough suppression may be hazardous and contraindicated in some
illnesses.
- Dosage guidelines for cough and cold mixtures are imprecise for
children.
- Parents must be educated about lack of proven effect and risks of
medications.
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