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B efore October 7, 2008, labels on OTC products indicated that products should not be used in children younger than 2 years. Because of a lack of clear directions, fatal cases occurred in children and were linked to over- doses or unsupervised ingestions of OTC cough and cold products. 1 Since the Consumer Healthcare Products Association made 2 major announcements: 1. Manufacturers of pediatric OTC cough and cold products volun- tarily modified their labels to indicate they should not be used in children younger than 4 years. 2. The FDA and the Centers for Disease Control and Prevention would create educational materi- als for parents, caregivers, and health care providers. As pharmacists, we have addition- al responsibilities to ensure that all patients, regardless of age, receive safe and effective therapy. Antihistamines When the body is exposed to aller- gens, such as pollen, mold, and ragweed, the allergen binds to and activates IgE. Upon activating IgE, basophils and mast cells release histamine and subsequent inflam- matory mediators, ultimately result- ing in allergic rhinitis (AR). The most common manifestations of AR include conjunctivitis, rhinorrhea, nasal congestion, coughing, wheez- ing, sneezing, or headache. 2 To properly treat symptoms, anti- histamines are given to reversibly antagonize the activation of hista- mine-1 receptors in the respiratory, gastrointestinal, and cardiovascular tracts. In mild cases, they are given on an as-needed basis. Oral antihis- tamines are divided into first-gen- eration antihistamines (FGAs) and second-generation antihistamines (SGAs), with SGAs preferred over FGAs due to better safety profiles. FGAs, such as chlorpheniramine, diphenhydramine, and bromphe- niramine, are lipophilic and read- ily cross the blood–brain barrier, resulting in sedation and cogni- tive impairment. Adverse effects (AEs) include drowsiness, dizziness, insomnia, and nervousness. Although SGAs have a lower incidence of AEs, SGAs are ineffec- tive at lessening cough associated with the common cold and, there- fore, should not be used. If a child displays any cold symptoms, FGAs should not be used because they have no proven, published clinical benefits. Moreover, if the child is younger than 6 years, the FDA rec- ommends pediatric patients receive only 1 antihistamine at a time, and even then, only those with 1 ingre- dient. 3 Chlorpheniramine and brom- pheniramine should be given every 6 to 8 hours as needed, although brompheniramine is not sold over the counter as an individual drug (Table 1); diphenhydramine should be given every 6 hours as needed (Table 2) 3 . Decongestants Decongestants are classified as sympathomimetics that cause vaso- constriction and alleviate muco- sal edema by stimulating alpha receptors along the nasal mucosa. 4 Systemic decongestants relieve nasal 68 PharmacyTimes.com December 2015 Pediatric Pulse Cough and Cold Concoctions: Making the Correct Choice TABLE 1: CHLORPHENIRAMINE AND BROMPHENIRAMINE DOSING IN CHILDREN OLDER THAN 6 YEARS Weight (lb) Dose (mg) 22-32 1 33-43 1.5 44-54 2 55-65 2 66-76 3 77-87 3 88+ 4 TABLE 2: DIPHENHYDRAMINE DOSING IN CHILDREN OLDER THAN 6 YEARS 3 Weight (lb) Dose (mg) 20-24 9.375 25-37 12.5 38-49 18.75 50-99 25 100+ 50 Brian J. Catton, PharmD