Walking the aisles the other day, we came across a couple products that at first intrigued us, then confounded us, and finally concerned us. What caught our eye was Dr. Cocoa’s cough syrup for children. Most large chains carry this stuff, or at least the “non-drowsy” version and the nighttime version. I found it in my market, Wal-Mart and a couple others that I looked at.
The non-drowsy version is a sweetened, chocolate flavored syrup containing 7.5mg/5ml of dextromethorphan (DM). Things like Robitussin DM contain 10mg/5ml of DM and do not have dosing for ages under 12. Dr. Cocoa’s has a 6 to 12 year old take a maximum of 40ml per day for a total of 60mg of DM in a day. The nighttime Dr. Cocoa’s is in the same syrup but has diphenhydramine as its cough controller. Disregarding the possible duplication of active ingredients, there are many reasons why I think Dr. Cocoa may be an over-priced shot of chocolate syrup. I hope you remember diphenhydramine is Benadryl and is also found in many OTC sleep aids.
We just had to try this stuff! I bought a bottle of the non-drowsy syrup and several of our staff, myself, and the interns gave it a try. Reactions varied from, “Wow! This stuff is just like Hershey’s syrup!” to “Um, that made me nauseous.” It did have the look and mouth feel of chocolate syrup, although its main sweetener is sucralose. It does have actual cocoa in it and is very sweet and chocolate-y. So much like chocolate syrup that I was tempted to try it on some plain vanilla ice cream that we had in the freezer. One staff did comment that this stuff would have to be locked up in the liquor cabinet to keep her kids from chugging it down.
Dr. Cocoa’s is marketed for ages 4 to 13, with 5ml every 6 to 8 hours for ages 4 to under 6, 10ml for ages 6-12, and then a big jump to 20ml every 6 to 8 hours for those lucky 13-year-olds. With 20ml, you could warm it up a bit and have yourself a nice hot fudge sundae! No nuts on mine, please.
This whole category is somewhat of a trick though. A study by Penn State published in JAMA showed that neither DM nor diphenhydramine worked any better than placebo! In fact, the winner of the blinded study was plain honey! It is not unreasonable to conclude that the hundreds of cough syrups that we sell are easily replaced by a couple teaspoonfuls of honey. Oh sure, maybe the drowsiness helps us get a good night’s rest and perhaps the sweet syrupy vehicle is what quiets our cough, but the “active ingredients” are really a big waste of money. It’s all in the marketing. Customer belief is one of the strongest indicators of product success.
Let me clear, however, dextromethorphan is a serious drug, just not a great cough suppressant. It is being studied for its neuroprotective abilities in the treatment of Parkinson’s disease and traumatic brain injury. For the clinical minded, DM has “inhibitory effects on glutamate-induced neurotoxicity via NMDA receptor antagonist, sigma-1 receptor agonist, and voltage-gated calcium channel antagonist actions.” Whew! DM is also an abused drug, popular as a cheap and available alternative to Ecstasy. In high doses, DM antagonism of the NMDA receptors can lead to hallucinations and other mental breaks with reality (dissociative effects) and it has SSRI like effects that can lead to serotonin syndrome when coupled with ubiquitous SSRI antidepressants. Do we really want to get our four-year-olds started on a drug like this? In a tasty, sweet, chocolate syrup?
Coughs are often needed.
Let’s take a brief side-track to revisit Robitussin DM. The regular stuff has, per teaspoonful (5ml), 10mg of DM and 100mg of guaifenesin. The Peak Cold version has the same DM but bumps the guaifenesin to 200mg. Either concentration is likely sub-therapeutic since you likely need over 2,000mg/day of guaifenesin to have an effect which means the whole bottle would last an adult for two days and would need to be taken around the clock. Guaifenesin works best in a well-hydrated patient. Mucus should be 90% water and all the guaifensin in the whole bottle will not help if the patient is not well hydrated. On yet another side-track, guaifenesin may help thin cervical mucus as well and so is used to enhance fertility. Sperm much prefer swimming through nice, thin, watery mucus. Guaifenesin is also being tried in fibromyalgia patients. One of the main drawbacks to these high doses is that the effective dose for expectorant action is very close to the emetic dose, resulting in a significant patients that vomit and so discontinue the drug. Just drink your water, your body will thank you.
Last time I had a cold, I drank hot lemonade sweetened with honey and with a bit of ginger. It made me feel better, although that’s all in my mind.
Oh, by the way, if you visit the Dr. Cocoa web site, you’ll likely get a cookie that will pop up ads or coupon offers on other cough and cold pages that you visit. Trick or treat, indeed.