Acute cough (<3 weeks in duration) generally does not require pharmacologic treatment, especially in children. Suppression of productive cough may be harmful. Management of patients with cough should include elimination of any precipitating factor (e.g., cigarette smoking) and treatment of any underlying cause such as upper airway cough syndrome, gastroesophageal reflux disease, asthma, or other pulmonary disease.

An oral solution (Vituz – Hawthorne) containing two old drugs, the centrally-acting opioid hydrocodone bitartrate and the first-generation H₁-antihistamine chlorpheniramine maleate, has been approved by the FDA for relief of cough and [other] symptoms associated with upper respiratory allergies or a common cold in adults. Several extended-release products containing hydrocodone and chlorpheniramine are available as capsules and suspensions and have been used for years for similar indications. Vituz is classified as a schedule III controlled substance, but the FDA has asked the DEA to reclassify hydrocodone products as schedule II.

The FDA recently warned that accidental ingestion of the antitussive benzonatate (Tessalon Perles, and others) by children less than 10 years old can be fatal.1 This widely prescribed oral agent, which has been available in the US since 1958, can also cause severe morbidity and death in older children and adults, and not only in overdosage.

Benzonatate is a polyglycol derivative structurally related to procaine and tetracaine. It acts peripherally on stretch receptors in the lower respiratory tract to suppress the cough reflex. If the patient chews or sucks the liquid-filled capsules or "softgels", the drug can cause laryngospasm, bronchospasm and circulatory collapse. Adverse effects that can occur after swallowing an intact capsule include a feeling of numbness in the chest, mental confusion, a sensation of burning in the eyes, and visual hallucinations.

Taken in overdose, benzonatate can rapidly cause seizures, cardiac arrhythmias and death. Serious adverse outcomes reported to the National Poison Center between 2000 and 2006 occurred in 116 patients (41 in children <6 years old), with 4 deaths.2 The 5 children known to the FDA who died from benzonatate ingestion were ≤2 years old and some apparently took only one or two capsules. In one well-documented case report, a 17-year-old girl who intentionally took 10 or more 200-mg capsules developed seizures, cardiac arrest from which she was resuscitated, and then blindness, which persisted.3 When a cough suppressant is truly necessary, dextromethorphan or even codeine might be a safer choice.

1. FDA. FDA Drug Safety Communication: Death resulting from overdose after accidental ingestion of Tessalon (benzonatate) by children under 10 years of age. Available at www.fda.gov/Drugs/DrugSafety/ucm236651.htm. Accessed January 27, 2011.

2. ML Winter et al. Benzonatate ingestion reported to the National Poison Center Database System (NPDS). J Med Toxicol 2010; 6:398.

3. V Cohen et al. Cardiac arrest with residual blindness after overdose of Tessalon (benzonatate) Perles. J Emerg Med 2009 Nov 4 (epub).

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