This may or may not be of interest to you.  Enjoy your day.

Veronica L. Gunn, MD, Samina H. Taha, MD, Erica L. Liebelt, MD, and
Janet R. Serwint, MD, "Toxicity of Over-the-Counter Cough and Cold
Medications", Pediatrics, September 1, 2001, Vol. 108, Num. 0, pp. e52

"Over-the-counter (OTC) cough and cold medications are marketed
widely for relief of common cold symptoms, and yet studies have failed
to demonstrate a benefit of these medications for young children. In
addition, OTC medications can be associated with significant morbidity
and even mortality in both acute overdoses and when administered in
correct doses for chronic periods of time. Physicians often do not
inquire about OTC medication use, and parents (or other caregivers)
often do not perceive OTCs as medications. We present 3 cases of
adverse outcomes over a 13-month period including 1 death as a result
of OTC cough and cold medication use. We explore the toxicities of OTC
cough and cold medications, discuss mechanisms of dosing errors, and
suggest why physicians should be more vigilant in specifically
inquiring about OTCs when evaluating an ill child."

"Colds, coughs, and upper respiratory infections are common childhood
illnesses. The average child suffers from 6 to 10 colds per year, and
each cold can last from 10 to 14 days, providing several days and
nights of discomfort for the child as well as for his/her caregiver.
Many times parents will turn to one of many hundreds of cough and cold
preparations for relief. However, over-the-counter (OTC) cough and cold
preparations although generally safe have no demonstrated benefit. No
studies have proven the efficacy of cough and cold preparations in
facilitating recovery from these illnesses, and most children will
eventually improve on their own. However, a small number of children
may suffer significant adverse effects from the administration of the
very cough and cold formulations they were given in an attempt to
relieve their symptoms. For example, the Food and Drug Administration
recently issued an advisory to remove phenylpropanolamine (PPA) a
common constituent of OTC decongestants from those products because of
concern for increased risk of hemorrhagic stroke."

"OTC cough and cold preparations are nearly ubiquitous, and are
marketed for the relief of those most irritating symptoms of the common
cold: rhinorrhea and cough. Although they may alleviate some symptoms
in adolescents and adults, many studies have demonstrated that OTC
cough and cold preparations do not achieve such claims in the younger
pediatric population. In fact, studies in children of the immediate,
short-term (within 48 hours), and long-term (after 72 hours) effects of
cough and cold preparations showed no significant difference between
OTC medications and placebo in the reduction of cough. In addition, OTC
cough and cold medications are associated with potentially serious side
effects."

"In 1997, the American Academy of Pediatrics (AAP) issued a statement
on the use of codeine- and dextromethorphan-containing cough remedies
in children, concluding that physicians should clearly educate parents
about the known risks and lack of benefits of these medications. We
chose to report these cases because they represent the range of
severity of adverse outcomes that can be seen with OTC cough and cold
preparations. In addition, a review of the recent literature does not
reveal reports of heart failure or death attributable to such
medications. Finally, our case reports from a single institution
reflect 3 episodes in just over 1 year that required admission, and
most likely only represent the "tip of the iceberg" of adverse outcomes
attributable to OTC cough and cold preparations."

"The potential toxicities of cough and cold medicines vary with their
composition. Many products contain multiple substances including a
decongestant, cough suppressant, antihistamine, and/or
antipyretic/analgesic. Pseudoephedrine and PPA are sympathomimetics
that reduce nasal congestion by stimulating the -andrenergic receptors
on vascular smooth muscles. Clinical toxicity presents with central
nervous system (CNS) stimulation, hypertension, and tachycardia with
ephedrine or pseudoephedrine ingestion, and bradycardia with PPA
ingestion. CNS stimulation can manifest as extreme agitation,
restlessness, insomnia, psychosis, and seizures. Serious complications
after decongestant ingestions and/or overdoses include hypertension,
tachycardia, bradycardia, seizures, stroke, and cerebral hemorrhage.
Dysrhythmias, myocardial infarction, and ischemic bowel infarction have
also been reported."

"Many reports of severe hypertension after therapeutic and toxic
doses of PPA have been published, some of which resulted in
intracranial hemorrhage and death."

"Many cough and cold preparations even include antihistamines such as
chlorpheniramine and brompheniramine although histamine has not been
shown to contribute to the symptoms seen in the common cold. Adverse
effects and clinical toxicity of antihistamines are characterized by a
spectrum of anticholinergic symptoms and CNS depression. Tachycardia,
blurred vision, agitation, hyperactivity, toxic psychoses, and seizures
may be evident. Cardiac dysrhythmias including torsades de pointes have
also been reported. Dextromethorphan, an antitussive, has also been
associated with toxic side effects such as lethargy, stupor,
hyperexcitability, ataxia, abnormal limb movements, and coma."

"Cough and cold medicines, therefore, are not administered without
risk. In 1 analysis of poison control reports of 249,038 exposures to
cough and cold preparations in children <6 years old, there were 72
"major events" and 4 deaths. These numbers are probably falsely low
resulting from reliance of this data on voluntary reporting. Other
children may have adverse outcomes from cough and cold preparation use,
but may not be reported to the poison control centers due to
self-limited reactions, failure to recognize the reaction (eg, the
child slept through the sedation), lack of reporting by the medical
facility, or a lack of acknowledgment that OTC medications had been
administered."

"In addition to side effects of the various ingredients, OTC cough
and cold preparations also present potential hazards due to dosing
errors. The first and third case reports demonstrate negative outcomes
attributable to acute and chronic dosing errors. Little published data
exists on levels of OTC cough and cold preparations in infants and
children; thus, dosing guidelines historically have been extrapolated
from adult data, making them imprecise for children. In 2 studies,
caregivers reported that they primarily followed dosing guidelines on
the medication package; however, this too allows for many potential
errors. They can misunderstand the recommended dose, frequency or
length of therapy, use an incorrect measuring device, or even give the
wrong preparation. In our second case report, well-intentioned parents
were giving their child what they perceived to be only an antipyretic;
however, because of package labeling the Cold portion of the name
Children's Tylenol Cold was in much smaller print they did not realize
that what they had actually been giving was a cough and cold
preparation."

"Some parents may intentionally give children supratherapeutic doses
of cough and cold preparations, exceeding either the recommended dose
amount or length of therapy. When appropriate doses of pediatric
formulations don't achieve the desired outcome, parents may increase
the dose, or give adult preparations that may be perceived as stronger.
Kapasi et al noted in a study of acetaminophen use, that a significant
percentage of poisonings from acetaminophen were secondary to excessive
dosing, rather than unintentional ingestion. In the third case report,
the child tragically died from an overdose of cough and cold
medications that likely had been persistently administered because of
continued symptoms in the child."

"Other parents, while recognizing that OTC cough and cold medications
do not relieve the cold symptoms, may continue to use these medications
for 1 of the side effects sedation. Additionally, many parents may
simply be unaware of the potentially serious side effects of OTC cough
and cold medications."

"Despite the risks of OTC cough and cold medicines, many parents
believe they should treat their children's cold symptoms with
medication. Cold remedies are a formidable industry; in 1990 alone,
nearly $2 billion was spent on OTC cough and cold preparations
nationwide. In 1991, Hutton et al conducted a randomized, controlled
trial evaluating the efficacy of an antihistamine-decongestant
preparation versus placebo, and noted that parents reported greater
symptom improvement in children who received medicine even if it was a
placebo. This parental observational bias suggests that parents in this
study felt the need to treat their children's cold symptoms, and
perceived more improvement when they received therapy."

"Many providers fail to give specific instructions on OTC cough and
cold medication use even when they are aware that the patient is using
them. In addition, some providers have a lack of knowledge regarding
the various ingredients in cough and cold preparations. Finally, not
only are many physicians unsuccessful in educating parents about the
risks of OTC cough and cold preparations, some physicians continue to
prescribe them for their patients despite their lack of demonstrated
efficacy. Gadomski and Horton described 2 such cases where a
physician-prescribed cough and cold preparation produced an adverse
outcome in the patient because of inappropriate dosing by the parents.
Although the AAP guidelines do not state that physicians should not
prescribe OTC cough and cold preparations, they do clearly state that
physicians have a responsibility to educate parents about the lack of
benefit and known risks of OTC cough and cold preparations. It is our
belief that for those families who insist on using OTC cough and cold
preparations, physicians should negotiate to discontinue use in 2 days
if there is no appreciated benefit."

"Three cases of children experiencing significant adverse effects and
toxicity from OTC cough and cold preparations are presented. Health
care providers have the opportunity to intervene by inquiring
specifically about OTC cough and cold medication use, and by educating
parents on the lack of demonstrated benefit and known risks in the
pediatric population as recommended by the AAP."

http://www.healthsentinel.com/briefs.php?event=briefs_print_list_item&id=29&titl
e=Cough%20and%20Cold%20Medications

This may be of interest to you as well.  Enjoy your day.

Veronica L. Gunn, MD, Samina H. Taha, MD, Erica L. Liebelt, MD, and
Janet R. Serwint, MD, "Toxicity of Over-the-Counter Cough and Cold
Medications", Pediatrics, September 1, 2001, Vol. 108, Num. 0, pp. e52

"Over-the-counter (OTC) cough and cold medications are marketed
widely for relief of common cold symptoms, and yet studies have failed
to demonstrate a benefit of these medications for young children. In
addition, OTC medications can be associated with significant morbidity
and even mortality in both acute overdoses and when administered in
correct doses for chronic periods of time. Physicians often do not
inquire about OTC medication use, and parents (or other caregivers)
often do not perceive OTCs as medications. We present 3 cases of
adverse outcomes over a 13-month period including 1 death as a result
of OTC cough and cold medication use. We explore the toxicities of OTC
cough and cold medications, discuss mechanisms of dosing errors, and
suggest why physicians should be more vigilant in specifically
inquiring about OTCs when evaluating an ill child."

"Colds, coughs, and upper respiratory infections are common childhood
illnesses. The average child suffers from 6 to 10 colds per year, and
each cold can last from 10 to 14 days, providing several days and
nights of discomfort for the child as well as for his/her caregiver.
Many times parents will turn to one of many hundreds of cough and cold
preparations for relief. However, over-the-counter (OTC) cough and cold
preparations although generally safe have no demonstrated benefit. No
studies have proven the efficacy of cough and cold preparations in
facilitating recovery from these illnesses, and most children will
eventually improve on their own. However, a small number of children
may suffer significant adverse effects from the administration of the
very cough and cold formulations they were given in an attempt to
relieve their symptoms. For example, the Food and Drug Administration
recently issued an advisory to remove phenylpropanolamine (PPA) a
common constituent of OTC decongestants from those products because of
concern for increased risk of hemorrhagic stroke."

"OTC cough and cold preparations are nearly ubiquitous, and are
marketed for the relief of those most irritating symptoms of the common
cold: rhinorrhea and cough. Although they may alleviate some symptoms
in adolescents and adults, many studies have demonstrated that OTC
cough and cold preparations do not achieve such claims in the younger
pediatric population. In fact, studies in children of the immediate,
short-term (within 48 hours), and long-term (after 72 hours) effects of
cough and cold preparations showed no significant difference between
OTC medications and placebo in the reduction of cough. In addition, OTC
cough and cold medications are associated with potentially serious side
effects."

"In 1997, the American Academy of Pediatrics (AAP) issued a statement
on the use of codeine- and dextromethorphan-containing cough remedies
in children, concluding that physicians should clearly educate parents
about the known risks and lack of benefits of these medications. We
chose to report these cases because they represent the range of
severity of adverse outcomes that can be seen with OTC cough and cold
preparations. In addition, a review of the recent literature does not
reveal reports of heart failure or death attributable to such
medications. Finally, our case reports from a single institution
reflect 3 episodes in just over 1 year that required admission, and
most likely only represent the "tip of the iceberg" of adverse outcomes
attributable to OTC cough and cold preparations."

"The potential toxicities of cough and cold medicines vary with their
composition. Many products contain multiple substances including a
decongestant, cough suppressant, antihistamine, and/or
antipyretic/analgesic. Pseudoephedrine and PPA are sympathomimetics
that reduce nasal congestion by stimulating the -andrenergic receptors
on vascular smooth muscles. Clinical toxicity presents with central
nervous system (CNS) stimulation, hypertension, and tachycardia with
ephedrine or pseudoephedrine ingestion, and bradycardia with PPA
ingestion. CNS stimulation can manifest as extreme agitation,
restlessness, insomnia, psychosis, and seizures. Serious complications
after decongestant ingestions and/or overdoses include hypertension,
tachycardia, bradycardia, seizures, stroke, and cerebral hemorrhage.
Dysrhythmias, myocardial infarction, and ischemic bowel infarction have
also been reported."

"Many reports of severe hypertension after therapeutic and toxic
doses of PPA have been published, some of which resulted in
intracranial hemorrhage and death."

"Many cough and cold preparations even include antihistamines such as
chlorpheniramine and brompheniramine although histamine has not been
shown to contribute to the symptoms seen in the common cold. Adverse
effects and clinical toxicity of antihistamines are characterized by a
spectrum of anticholinergic symptoms and CNS depression. Tachycardia,
blurred vision, agitation, hyperactivity, toxic psychoses, and seizures
may be evident. Cardiac dysrhythmias including torsades de pointes have
also been reported. Dextromethorphan, an antitussive, has also been
associated with toxic side effects such as lethargy, stupor,
hyperexcitability, ataxia, abnormal limb movements, and coma."

"Cough and cold medicines, therefore, are not administered without
risk. In 1 analysis of poison control reports of 249,038 exposures to
cough and cold preparations in children <6 years old, there were 72
"major events" and 4 deaths. These numbers are probably falsely low
resulting from reliance of this data on voluntary reporting. Other
children may have adverse outcomes from cough and cold preparation use,
but may not be reported to the poison control centers due to
self-limited reactions, failure to recognize the reaction (eg, the
child slept through the sedation), lack of reporting by the medical
facility, or a lack of acknowledgment that OTC medications had been
administered."

"In addition to side effects of the various ingredients, OTC cough
and cold preparations also present potential hazards due to dosing
errors. The first and third case reports demonstrate negative outcomes
attributable to acute and chronic dosing errors. Little published data
exists on levels of OTC cough and cold preparations in infants and
children; thus, dosing guidelines historically have been extrapolated
from adult data, making them imprecise for children. In 2 studies,
caregivers reported that they primarily followed dosing guidelines on
the medication package; however, this too allows for many potential
errors. They can misunderstand the recommended dose, frequency or
length of therapy, use an incorrect measuring device, or even give the
wrong preparation. In our second case report, well-intentioned parents
were giving their child what they perceived to be only an antipyretic;
however, because of package labeling the Cold portion of the name
Children's Tylenol Cold was in much smaller print they did not realize
that what they had actually been giving was a cough and cold
preparation."

"Some parents may intentionally give children supratherapeutic doses
of cough and cold preparations, exceeding either the recommended dose
amount or length of therapy. When appropriate doses of pediatric
formulations don't achieve the desired outcome, parents may increase
the dose, or give adult preparations that may be perceived as stronger.
Kapasi et al noted in a study of acetaminophen use, that a significant
percentage of poisonings from acetaminophen were secondary to excessive
dosing, rather than unintentional ingestion. In the third case report,
the child tragically died from an overdose of cough and cold
medications that likely had been persistently administered because of
continued symptoms in the child."

"Other parents, while recognizing that OTC cough and cold medications
do not relieve the cold symptoms, may continue to use these medications
for 1 of the side effects sedation. Additionally, many parents may
simply be unaware of the potentially serious side effects of OTC cough
and cold medications."

"Despite the risks of OTC cough and cold medicines, many parents
believe they should treat their children's cold symptoms with
medication. Cold remedies are a formidable industry; in 1990 alone,
nearly $2 billion was spent on OTC cough and cold preparations
nationwide. In 1991, Hutton et al conducted a randomized, controlled
trial evaluating the efficacy of an antihistamine-decongestant
preparation versus placebo, and noted that parents reported greater
symptom improvement in children who received medicine even if it was a
placebo. This parental observational bias suggests that parents in this
study felt the need to treat their children's cold symptoms, and
perceived more improvement when they received therapy."

"Many providers fail to give specific instructions on OTC cough and
cold medication use even when they are aware that the patient is using
them. In addition, some providers have a lack of knowledge regarding
the various ingredients in cough and cold preparations. Finally, not
only are many physicians unsuccessful in educating parents about the
risks of OTC cough and cold preparations, some physicians continue to
prescribe them for their patients despite their lack of demonstrated
efficacy. Gadomski and Horton described 2 such cases where a
physician-prescribed cough and cold preparation produced an adverse
outcome in the patient because of inappropriate dosing by the parents.
Although the AAP guidelines do not state that physicians should not
prescribe OTC cough and cold preparations, they do clearly state that
physicians have a responsibility to educate parents about the lack of
benefit and known risks of OTC cough and cold preparations. It is our
belief that for those families who insist on using OTC cough and cold
preparations, physicians should negotiate to discontinue use in 2 days
if there is no appreciated benefit."

"Three cases of children experiencing significant adverse effects and
toxicity from OTC cough and cold preparations are presented. Health
care providers have the opportunity to intervene by inquiring
specifically about OTC cough and cold medication use, and by educating
parents on the lack of demonstrated benefit and known risks in the
pediatric population as recommended by the AAP."

http://www.healthsentinel.com/briefs.php?id=029&title=Cough+and+Cold+Medications
&event=briefs_print_list_item

Diphenhydramine (& pseudoephedrine on real bad days) for my antihistamine
relief, personally. Me & my liver hate APAP.

That makes a lot of sense and is what I try to do.  I have aspirin, tylenol and
ibuprofen on the shelf but none of the mixtures.  If I want a decongestant I
take pseudoephedrine, for an expectorant guaifenesin and for pain I alternate
tylenol and ibuprofen.  If I start to have a sneezing bout from pollen I take
allegra, 12 hour.  None of that 24 hour stuff for me.  And I take 81 mg. aspirin
daily because they say that is good to do.  

Those are the only things I use and I am pretty healthy.  

Ora