Issue 17.
Cough Medications in
Children
A recent Drugs and Therapeutics Bulleting discussed
the commonest problem in medicine, coughs in children. Over-the-counter medicines marketed
for treating cough are widely available, but relatively few can be prescribed on the NHS.
In children, the commonest cause of upper
respiratory tract symptoms is probably viral infection. On average, children have four to
eight such infections every year. In addition, respiratory allergies often develop during
childhood and this can complicate diagnosis of the cause of cough.
Diagnosing the cause of a cough is important since
cough itself should not necessarily be the target for treatment. In children with a
persistent night-time cough or a persistent exercise-induced cough, chronic illnesses such
as asthma or other atopic conditions, cystic fibrosis, or inhalation of a foreign body
should be considered.
Cough may persist long after an upper respiratory
tract infection so there may be no obvious underlying cause. Reassurance and explanation
to the parents to this effect is often sufficient, and backing this up with an information
leaflet to take home may be useful. The usual reasons for giving a cough medication to a
child is if the cough is thought to be dry and causing discomfort or pain, or if it is
severe enough to seriously disturb sleep.
Drugs for cough suppression available on an NHS
prescription include codeine phosphate and pholcodine. Around 200 over-the-counter (OTC)
combination products are currently listed in the BNF.
There are five placebo-controlled studies of the use
of cough medications in children. All are small in numbers and generally not well
controlled.
Cough suppressants can do considerable harm. A
report has identified 430 children with acute codeine intoxication, 8 experienced
respiratory arrest requiring intubation and mechanical ventilation. Systemic products
containing codeine can cause hyperactivity and constipation.
Cough suppressants containing codeine or other opioid analgesics
should be avoided altogether in children under 1 year of age, sympathomimetics are not
licensed for use in those under 2 years.
The consequences of cough in a distressed child can
leave parents feeling stressed and helpless, which in turn can worsen the child’s
distress and so further exacerbate the stress within the family. We suggest that a simple
cough linctus is the most appropriate treatment in these circumstances. Parents should
also ensure that the child is drinking enough, that any high temperature is treated (e.g.
with paracetamol) and that the room is not too dry.
Cough due to viral upper respiratory tract
infections are extremely common. In most children, the cough does not require any
medication. When parents are worried, explanation and reassurance are usually all that is
needed. Sometimes, a cough can lead to stress within the family, especially if it is slow
to resolve. II is important to look for any underlying cause if symptoms prove persistent.
Ref
to BNF general
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Blood, blood, glorious blood
The first step towards better blood transfusion has
been made with the publication of a circular from the Welsh Office detailing the actions
required by NHS trusts and clinicians to improve blood transfusion practice. From April
1999 all NHS trusts, where blood is transfused, should have multidisciplinary hospital
transfusion committees and participate in the annual Serious Hazards of Transfusion (SHOT)
enquiry. They have a further year to implement local protocols for blood transfusion,
which should be based on the best available evidence and are supported by adequate
training; an onerous task in 12 months.
Furthermore, to make sure that those concerned are
not left idle, they also have to investigate the feasibility of autologous blood
transfusion and make certain that patients are aware of the possibility. Perioperative
cell salvage (PCS), a method to reduce the exposure of patient to allogeneic blood and to
reduce the quantity of blood used, must also be considered. Locally, Morriston Hospital
NHS Trust has introduced PCS.
The circular emphasises that blood transfusion in
the UK is very safe but that there is no room for complacency. The first SHOT report in
March 1998 indicated that there were 169 reported serious hazards following blood
transfusion. It will come as no surprise that 81 involved a blood component being given to
the wrong patient and that only eight involved viral and bacterial infections. This is
surely one area where audit and procedural review should be used to identify preventable
hazards.
There are several other recommendations contained
within the circular requiring extensive further work and the national blood services, the
blood user groups and the professions will need to address these in the very near future.
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Consensus in stroke
management
The BMJ of 10 Jan had an article on this subject.
Besides meta-analyses of clinical trials, one of the fashions in clinical management at
the end of the 20th century is consensus statements. Stroke management has not
escaped this plethora of consensus statements.
The goal of these consensus statements is not bad, since they
attempt to reconcile scientific data from clinical trials, traditions in clinical practice
and the personal opinions of participants.
Statements produced at the recent Royal College of
Physicians of Edinburgh consensus conference are simple, even often simplistic, but they
may provide a good basis for non-experts involved in stroke management, since they include
recent updates on treatment and prevention of stroke. The roles of antiplatelet therapy,
anticoagulant therapy, thrombolytic therapy, and carotid surgery are reviewed, and these
are followed by five concluding remarks that emphasise the need for better knowledge and
collaboration. The statements are well formulated and concise, though people may disagree
about the details.
One of the characteristics of the Edinburgh
consensus statement is its flavour of UK practice, which is all right if readers recognise
it for what it is. However, this suggests that future consensus meetings should try to
acknowledge controversies at a truly international level in order to avoid local
connotations.
Ref
(web)
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Nurse telephone consultation
A BMJ article back in October showed using a
randomised controlled trial over a year of 156 matched pairs examined over 14,000 calls.
Nurse telephone consultation produced substantial changes in call management, reducing
overall workload of general practitioners by 50% while allowing callers faster access to
health information and advice.
It was not associated with an increase in the number
of adverse events. This model of out-of-hours primary care is safe and effective.
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Quality of care is the degree to which health
services for individuals and populations increase the likelihood of desired health
outcomes and are consistent with current professional knowledge.
Lohr, Medicare. Washington DC.
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