Menthol for Sore Throat, Colds and Coughs… Should we use it?

I am often asked about the use of Vick’s Vapo Rub (or other menthol products and refer to all brands in this post).

We see menthol for vaporizer dispensers, in cough drops, and the good ole jar of rub that mom used on our chests when we were sick.

But should we use it?

Cough drops

Menthol is a mild anesthetic that provides a cooling sensation when used as a cough drop. It is basically a local anesthetic which can temporarily numb the nerves in the throat that are irritated by the cold symptoms and provide some relief.

Interestingly, menthol is added to cigarettes in part to numb the throat so new smokers can tolerate the smoke irritation better. Hmmm…

Menthol cough drops must be used as a lozenge and not chewed or swallowed because the menthol must slowly be exposed to the throat for the numbing effect. They are not recommended for young children due to risk of choking.

Science lacks strong evidence, but the risk to most school aged children is low and it is safer than most other cough medicines. For these reasons, I use the “if it seems to help, use it” rule for children not at risk of choking.

Do not let any child go to sleep with one in his mouth. First, he might choke if he falls asleep with it in his mouth. Second, we all need to brush teeth before sleeping to avoid cavities!

Vaporized into the air

When it is put into a vaporized solution, menthol can decrease the feeling of need to cough.

Vaporized menthol should never be used for children under 2 years of age. They have smaller airways, and the menthol can cause increased mucus production, which plugs their narrow airways and may lead to respiratory distress.

Infants can safely use vaporizers (and humidifiers) that put water into the air without any added medications.

The rubs for the skin

We’ve all seen the social media posts supporting putting the menthol rubs on the feet during sleep to help prevent cough. That has never made sense to me. The link provided discusses that it is not a proven way to use the rubs.

Menthol studies show variable effectiveness. It has been shown to decrease cough from baseline (but the placebo worked just as well) and did not show improved lung function with  spirometry tests (but people stated they could breathe better) in this interesting study.  In other words, people felt better, but there really was no objective improvement.

Putting menthol rubs directly under the nose may actually increase mucus production according to a study published in Chest. In children under age 2, this could result in an increase in more plugging of their more narrow airways.

There might be a concern with putting any petrolatum based product in or near the nose. There is a more recent study that does show children ages 2-11 years with cough sleep better with a menthol rub on the chest.

Note: There is a Vick’s BabyRub that does not contain menthol. Its ingredients have not been proven to be effective. Some of the ingredients have their own concerns, but that does not fall into this discussion.

Cautions

Menthol products should never be used in children under 2 years of age. It can actually cause more inflammation in their airways and lead to respiratory distress.

Photo source: Angel caboodle at English Wikipedia [CC BY-SA 3.0 (https://creativecommons.org/licenses/by-sa/3.0) or GFDL (http://www.gnu.org/copyleft/fdl.html)], via Wikimedia Commons 

Camphor is another ingredient along with menthol in the rubs. It can be deadly if swallowed.

It has been known to cause seizures in children under 36 months when absorbed or ingested in high concentrations.

Menthol rubs in the US contain camphor in a concentration that’s felt to be safe if applied to intact skin in those over 2 years old.

Mucus membranes absorb medicines more readily than intact skin. Do not apply to nostrils, lips, or broken skin.

Do not allow children to handle these rubs. Apply only below their necks to intact skin.

Many people using these rubs experience skin irritation. Discontinue use if this happens.

What Doctors Want You To Know About Treating Colds (but are afraid to say)

When kids suffer from illness after illness all winter long, parents understandably get frustrated. Believe me, as a parent and a physician, I get it. Do you know what doctors want you to know  about treating colds?

This is a change from my usual blogging style because I want to share a Facebook post. I follow a few private Facebook Groups and in one for physicians the following post was shared. I tracked down the original author for permission to share publicly. He was not intending for this to reach a wide audience, but authorized me to share without his real name. He asked that I refer to him as Dr. Nate.

I did not write anything in the post or the comments I posted below, but I see value in it. It highlights the fears and desperation of many parents and the frustration that even doctors have in treating coughs and colds.

It might offend some because of its snarkiness, but it might help parents who are frustrated that their child is sick… again.

As you can see, Dr. Nate answers questions about treating a child’s cold and cough rather bluntly, but from the many, many positive responses, rather accurately. It’s a behind-the-scenes look at what doctors really want to say but can’t.

I’ll first post screenshots of the post and some of the replies (there were also GIFs and more comments of essentially the same “love it” responses) and then I copied the wording below for ease of reading.

Text:

Saw this posted over on ********* and figured this group would appreciate it the most given the snarkiness! ? #ParentingIsHard#TrueStory

“Shamelessly and unapologetically plagiarized from ***********:
And now, for a pediatric URI Q & A session with your friendly neighborhood doctor.
Q: My kid has had a cold for four days now, and he isn’t getting any better! What should I do?
A: most colds spent 4-5 days getting worse and 4-5 days getting better. Call me if it’s been consistently worsening for a week, and we’ll talk. Otherwise, regular supportive care is all we do for a cold.
Q: He’s coughing up green and yellow junk! My friend Becky says that mean he needs antibiotics.
A: normal viral colds involve a full rainbow of sputum colors. Green, yellow, and white junk tells you nothing about whether it’s viral or bacterial, especially in babies.
Q: My baby has had a cold for 3 weeks. What now?
A: probably not really. Your kid can have a cough that lingers for up to 4-6 WEEKS after recovering from a viral infection like RSV. If there’s no fever, and no other symptoms of infection, a cough alone is expected.
Q: But he’s been coughing for 3 weeks!!!
A: You will notice that 3 is less than 4-6. This does not surprise me.
Q: But that’s a long time!
A: tough. #ParentingIsHard
Q: But it’s really interfering with his sleep!
A: Oh, well in that case, let me go get the cure for the common cold and post viral cough that we doctors have been keeping secret. Lol, J/K – #PIH
Q: My friend Becky told me to come to the hospital because my baby had a fever of 99 degrees.
A: First off, in babies, a fever is 100.4 degrees. A temperature of 99 is not legally a fever. Second off, stop listening to Becky.
Q: does my child have a sinus infection?
A: since kids don’t really have sinuses, probably not. They may have small ethmoid sinuses that don’t often get infected, but they don’t have fully formed adult sinuses until they’re middle school aged. Those are the ones that get sinus infections.
Q: does my baby have bronchitis?
A: no. Just, no. Babies can get bronchIOLItis, but almost never get true bronchitis. And if they did, the treatment for bronchitis is not usually antibiotics.
Q: it’s been 30 days and he’s STILL coughing!
A: Wow, parenting really does suck. Nothing to do about it though.
Q: I want antibiotics
A: does your kid have strep, pneumonia, an ear infection, or a UTI? If not, tough.
Q: My kid has a runny nose, a sore throat, and a cough. Becky says it’s strep.
A: WTF did I say about listening to Becky?! Strep doesn’t cause runny nose and cough (except in babies under a year, which is a different entity than strep throat).
Q: My toddler has been sick for the last two months.
A: your kid, at this age, can get a dozen viral respiratory infections a year. Each one can last up to two weeks. You do the math – toddlers are sick almost just as often as they’re well.
Q: what about vitamin C and zinc?
A: MAYBE vitamin C prevents colds in certain subsets of the population, but not for everyone, and once you have a cold they won’t stop it. And don’t give your kid zinc.
Q: (something something essential oils or coconut)
A: the only natural treatment for a cough with good data is honey, and never give honey to a baby under 12 months.
Q: what over the counter medicine is best for a kid with a cold?
A: none of them. They all suck for kids. Tylenol and Motrin are good for fevers in general, but stay away from “cold and flu” medicines.
Q: Well, _I_ had a different experience than one of the above scenarios. I actually DID need antibiotics/ have a kid with a sinus infection/ found a worrisome reason for a lingering cough / got better with essential oils.
A: 1) that was likely a coincidence if it happened at all. 2) this is called an “outlier” and does not nullify the general rule 3) is this Becky? Go away Becky.
Q: All 6 of my kids are sick. What can I do?
A: Mirena, Nexplanon, and Depo-Provera are all good options for you.
Q: You’re a mean pediatrician
A: that’s not a question. But yes, yes I am.”
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Tamiflu status downgraded!

Those of you who follow my blog or are my patients know that I’ve never been a fan of Tamiflu. I’ve written To Tamiflu or Not To Tamiflu and I’ve posted Tamiflu from guest blogger, Dr. Mark Helm. Despite the CDC’s recommendation to use Tamiflu frequently, I rarely prescribe it. And when I do, I often find that the whole course isn’t completed because the kids don’t tolerate it well – usually vomiting, but occasionally they’ve had scary hallucinations. I haven’t seen very much benefit, especially given the cost (and often the difficulty of finding it during peak flu season).

WHO Downgrades Tamiflu

The World Health Organization (WHO) has recently downgraded the status of Tamiflu. The CDC and FDA will have to chime in for the US recommendations, but the WHO is a respected source of medical guidelines and I look forward to a response from the CDC.

Risks vs benefits

As I’ve said before, Tamiflu doesn’t seem to work as well as needed and it has significant side effects. Not all studies done on Tamiflu were published. Only studies showing a little benefit and minimal side effects were considered in making the recommendations to use it. If many studies show no benefit but aren’t published, it makes it seem better than it is. Most studies are done in adults, but studies in children for prevention of flu and treatment of flu also fail to show much benefit.

2013 review of all the studies done in adults found only a 20.7 hour reduction in symptoms (yes, less than one day). In the elderly and those with chronic diseases (among the highest risk adults) no reduction was found. They also found no evidence of decreasing the risks of pneumonia, hospital admission, or complications requiring an antibiotic. This same review also showed more side effects than commonly reported. Nausea, vomiting, and psychiatric side effects are common.

Will the CDC join in?

I hope that the CDC reviews its recommendations for antiviral use before the influenza season hits this year. Until then, plan on getting your family protected with the flu vaccine. It isn’t perfect, but it does help keep us from getting sick and it can help save lives!

 

tamiflu
Tamiflu is an antiviral used against influenza, but there are many questions of safety and efficacy.