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congestion and cough caused by postnasal drip and promote nasal or sinus drainage. Unlike systemic decongestants, nasal decongestants provide symptomatic relief of nasal congestion. Pseudoephedrine direct- ly and indirectly affects adrenergic activity in the nasal mucosa and throughout the body by stimulating alpha-1 and alpha-2 receptors by releasing norepinephrine. Although phenylephrine stimulates alpha-1 receptors, alpha-2 receptors are stimulated by oxymetazoline, nap- hazoline, and xylometazoline. Decongestant AEs include tachy- cardia, palpitations, restlessness, and psychological disturbances; however, AE incidence in nasal decongestants is lower because they are not as highly absorbed as systemic decongestants. Due to its dosage form, people who use nasal decongestants may experi- ence burning, stinging, sneezing, or local irritation. Patients using nasal decongestants should use them for up to 3 days to prevent rebound congestion. In all children, using a cool-mist vaporizer is advised to provide symptomatic relief rather than a warm-mist vaporizer or vaporizers that use menthol. 5 Expectorants Guaifenesin is the only OTC expec- torant available for use in chil- dren that works as a mucolytic. Guaifenesin breaks up phlegm and bronchial secretions, resulting in increased cough production and improved airway clearance. AEs of guaifenesin include nausea, vomit- ing, dizziness, and drowsiness. To ensure that guaifenesin works to its fullest potential, it should be taken with a full glass of water and adequate hydration should be maintained. If the productive cough lasts for more than 1 week or wors- ens, consultation with a pediatrician is highly recommended. Antitussives Codeine is the cornerstone in antitussive therapy by exerting its cough suppression properties in the medulla oblongata; if used at antitussive doses, codeine should not exhibit addictive properties. Dextromethorphan is an OTC anti- tussive composed of the d -isomer of codeine so that it exerts the same antitussive properties as codeine. AEs include drowsiness, dizziness, nausea, GI upset, and abdominal discomfort. Pharmacists should counsel par- ents about the lack of evidence supporting the use of antitussives in pediatric patients and the potential risks associated with their use. The FDA does not recommend dextro- methorphan be used in children younger than 4 years; instead, honey should be used to treat a cough. If that does not work, dex- tromethorphan should be given in doses up to 20 mg every 6 to 8 hours (Table 3). 6 Combination Products Many nonprescription cough and cold formulations contain more than 1 active ingredient to treat symptoms occurring simultaneously. Combination medications should be used if the corresponding symptom is present, but not if a different non- prescription product with the same active ingredient is currently being used. 3 Some examples of combina- tions include antihistamine/deconges- tant, antihistamine/antitussive, and antitussive/expectorant. Moreover, some products contain antipyretics (eg, acetaminophen) and analgesics (eg, ibuprofen), and should be dosed based on weight (Table 4 8 ). Alternative Therapies 7 Due to the lack of evidence prov- ing several cough and cold products are safe and effective for use in children, as well as FDA recommen- dations to not use any individual product in children younger than 4 years and combination products in children younger than 6 years, there are other ways to provide symptom- atic relief for pediatric with cough and cold symptoms. In the case of aches, children's acetaminophen and ibuprofen is recommended (although, due to its antipyretic properties, acetaminophen only should be used in cases of fever); aspirin is contraindicated due to its risk of causing Reye's syndrome in children. To provide relief from nasal congestion, using saline drops or a nasal irrigation solution to clear thick mucus from their nasal sinuses is advised. Also, encourage children to drink plenty of water and fluids to stay properly hydrated and assist in thinning out the mucus. n Brian J. Catton, PharmD, graduated from the Bernard J. Dunn School of Pharmacy at Shenandoah University in Winchester, Virginia, in 2010. He received the Distinguished Young Pharmacist Award from the New Jersey Pharmacists Association in 2014 and founded its New Practitioner Network in 2015. He is a scientific communications manager at AlphaBioCom in King of Prussia, Pennsylvania. His areas of interest include pediatrics, immunizations, drug-therapy management, social media, patient counseling, and immuno-oncology. For references and tables, go to PharmacyTimes.com/ publications/issue. MORE @ PHARMACY TIMES.COM Which cough and cold concoctions do you prefer? Tweet them @Pharmacy_Times TABLE 3: DEXTROMETHORPHAN DOSING AS SECOND-LINE TREATMENT FOR COUGH IN CHILDREN OLDER THAN 6 YEARS Weight (lb) Dose (mg) 16-31 2.5 32-47 5 48-63 7.5 64-79 10 80-95 12.5 96-129 15 130+ 20 TABLE 4: WEIGHT-BASED DOSING OF ANTIPYRETICS AND ANALGESICS 8 Drug Acetaminophen Ibuprofen Weight-based dose 10-15 mg/kg 5-10 mg/kg Dose frequency Every 4-6 hours Every 6-8 hours Maximum daily dose 75 mg/kg/day, or 3 g/day 40 mg/kg/day 70 PharmacyTimes.com December 2015