Syrup or No Syrup? The New Guidelines Changing How Doctors Treat Cough in Children

For many years, whenever parents had a child with a cough, it was reflex to offer them a spoon of cough syrup.  That is quickly changing. Throughout India, there has been a noticeable shift in the approach doctors take to prescribing cough syrups to children due to safety concerns and updated guidance.

A Wake-Up Call from Recent Events

Recent incidents of children dying after consuming contaminated cough syrups have opened the discussion about safety once again. Investigators found harmful substances in unacceptable amounts which demonstrated 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 script before purchase, especially for infants and young children.

In addition, the Union Health Ministry sent advisories to doctors requesting rational prescribing for cough syrups in children for true medical need and reminding states that most coughs are self-limiting, even if viral. This increased scrutiny 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.

1. Cough syrups do not treat the underlying infection; they only temporarily suppress symptoms.
2. Some ingredients can cause side effects such as drowsiness, vomiting, or, in rare cases, breathing problems — especially in children under 2 years.
3. 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, and recommended physician discretion in deciding to use fixed-dose combinations.

When Doctors Avoid Cough Syrups

As pediatricians, there are certain situations where we will clearly choose not to prescribe cough syrups:

1. In children less than or equal to 2 years old, the risk outweighs the benefit.
2. In mild dry, short coughs due to viral infections, where patients are improving.
3. In nighttime coughs from nasal drip or allergies, home remedies are actually more helpful.

We rely on supportive care in these conditions, which provides patients with equal or greater relief compared to medication.

When Cough Syrups Are Considered

There are specific instances where cough syrups can help — but these are the exception, not the rule.

1. Ongoing coughs that dry out the lungs and interrupt sleep after serious causes are excluded.
2. Coughs associated with allergies or asthma when cough medications exist to treat. It must be emphasized here that inhaled medications are the first choice in children with asthma, both for relief of acute episode and to prevent recurrence of symptoms.
3. If cough is due to a bacterial infection antibiotics are the primary intervention and cough syrup maybe given in addition for short duration to relieve symptoms.
4. Coughs that are “wet” but have thick secretions where an expectorant may help clear thick secretions.

Even in situations as these, the dosing is always calculated and provided based on the child’s age, weight and the parents are counseled 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 Doctor’s Checklist

1. Before prescribing anything, we assess:
2. Age and weight of the child
3. Type and duration of cough
4. Associated symptoms like fever, breathlessness, or chest pain
5. Underlying conditions such as asthma or allergies
6. Risk factors for complications

This helps us determine whether medication is necessary or whether watchful waiting and home care are safer options.

What Parents Can Do at Home

The involvement of parents is very important for recovery. Here are measures that are safe and effective:

1. Encourage your child to drinkmore fluids during illness. Warm fluids are good for hydration.
2. Saline nasal drops are helpful for examining nasal congestion during recovery.
3. Steam inhalation or humidified air is helpful for recovery.
4. Honey can be soothing to the throat (during recovery and if your child is older than 1 year of age).
5. Avoid asking your friendly neighborhood pharmacist for over-the-counter cough syrups for your child.

If your child has a persistently high temperature, fever, has difficulty breathing, blue lips, refusal to feed, consult your Pediatrician immediately.  If the cough lasts more than a week or is recurring frequently

The Bottom Line

Cough syrups are no longer prescribed automatically — and for good reason. Between safety concerns, limited effectiveness, and updated guidelines, paediatricians now approach each case with greater clinical caution. For parents, this means trusting the process, avoiding self-medication, and recognising that most childhood coughs don’t need a bottle of syrup — just time, care, and patience.

By Dr. Jyothi Raghuram Senior Consultant – General Pediatrics & Pediatric Rheumatology