Melanie Cole, MS (Host): There's no handbook for your child's health, but we do have a podcast featuring world-class clinical and research physicians covering everything from your child's allergies to zinc levels. This is Kids Health Cast by Weill Cornell Medicine. I'm Melanie Cole. And parents, listen up, because we're going to address questions about over-the-counter medications for you today. Joining me is Dr. Nikhil Menon. He's an Assistant Professor of Clinical Pediatrics at Weill Cornell Medicine.

Dr. Menon, thank you so much for being with us. Boy, when my kids were little, I could have used this podcast. So, let's start with fevers. I want to know, and I know parents want to know, what's considered a fever and when does a fever have to be treated?

Nikhil Menon, MD: Hey, Melanie. Thanks so much for having me. So, a fever is considered a temperature of 100.4 Fahrenheit, which is not to be confused with 104, but 100.4. And in Celsius, that's 38 degrees. For children under two months old, we consider fever to be an emergency. So in those cases for little babies, we say don't treat the fever, but actually take them straight to the ER so that we can make sure that there's no sign of like a serious infection.

For kids over two months, it's actually up to you. Fever is part of the normal immune response, so it can actually be argued that in some cases it's helpful. So in cases where a child is well-appearing, there's no medical need to treat the fever. But some children, they just don't feel well with the fever. You know, they breathe quickly, they look tired from the fever alone. So, for those kids, I always think it's worth treating. If they feel better with the medication, then they're okay. But if you treat the fever and they don't look better, then I think that's a good time to see the doctor.

There's also a rare condition called febrile seizures, where some kids actually have a seizure when they have a very high fever. If there's a child who has had a seizure in the past from a fever, we tell parents to treat the fever very aggressively. So in those kids, we always say to treat it.

Melanie Cole, MS: Okay. That was great answer. So, let's talk about if we are parents and the kids are uncomfortable from this fever and we want to give them something to make them more comfortable, bring it down a little bit. There's Tylenol. There's Motrin. Parents used to think maybe you alternate them if the fever was really high, like it was a fever from something. But what do we do? Is it Tylenol? Is it Motrin? Because they do different things, but they both can work on the fever to get well.

Nikhil Menon, MD: Totally agree. And Tylenol and Motrin are kind of the heavy hitters for us when it comes to fever, but they do have some differences. So, Tylenol works for fever and pain. And Tylenol's dosing is typically every four hours. Motrin is typically dosed every six hours, and while it works for fever and pain, it also works as an anti-inflammatory. So for something like a sprained ankle, Motrin is the one to go to because it helps with fever, pain, and also with any swelling that is associated with that sprained ankle. The dosing is a little more complicated for children. In adults, it's the same, you know, no matter who you are. But for children, the dosing is weight-based. So for young babies, especially kids under two years old, we always say ask your doctor, because they can help you figure it out based on how big or old the child is. For toddlers and school age children, I think it's fine to look at the bottle for dosing. And typically on the side of the bottle, it will tell you exactly how much to give.

There is one caveat, though, I just want to mention, because we get a lot of questions about this, and that is, for children's medications, which are liquids, Tylenol exists as two different kinds. There is an Infant Tylenol and a Children's Tylenol. But in effect, these are the same medication. It's the same concentration of medication per amount of liquid, just in a different bottle, and it's labeled as different things, Infant and Children's. For Motrin, these also exist as Infant and Children, but it's actually a different concentration of medicine. So for Motrin, it's very important that you are careful about giving the correct dose. And when you ask your doctor, "What's child's dose for Motrin?" Specify if you're giving Infant or Children's Motrin so that they know which dose to give you.

Melanie Cole, MS: This is so important. What a great episode this is. I can already tell. Now, thank you for telling us about Tylenol and Motrin because that can be confusing to people. What about allergy medication? Because kids get the sniffles, they get runny noses, sometimes it's a cold or RSV or the flu or COVID or whatever's going on right now. Sometimes it's just allergies, seasonal allergies. There are so many on the market, Dr. Menon, and also now some of them are behind the pharmacy counter. Benadryl, we know, makes our kids fall asleep, but Sudafed and those can make them run around hyper. So, what do we do with those things or do we just steer clear of them?

Nikhil Menon, MD: Ah, this is a question I get a lot. And we're coming into the fall season, which means there can be some allergies going on as well. So typically for allergic reactions and seasonal allergies, we give an antihistamine. The best known one is Benadryl, but it's also the oldest. And I looked this up recently, it's been around since the 1940s. And it also has the most side effects, such as you mentioned, drowsiness. But also, there is something like 10% of children that have a paradoxical response to Benadryl. And instead of becoming drowsy, they actually become hyperactive. And there's no real way to predict who is going to have which reaction when you give it to them.

But the good news is there are newer antihistamines, so called second generation antihistamines like Zyrtec, Claritin and Allegra. And these, I think, are much better than Benadryl because they have a faster onset, they last longer. For example, Zyrtec lasts about 18 hours instead of Benadryl's typical 4 to 6 hours, and they do not cause drowsiness. So even though Benadryl is a household name, I usually tend to recommend something like Zyrtec instead.

And on a related note, I do get a lot of questions from parents about using Benadryl for sedation, like if they're going on an airplane to make their kid a little sleepy, and I generally do not recommend this. Repeated Benadryl use has actually been associated with some developmental delays in adolescence and other problems in older adults, probably because it crosses the blood-brain barrier, which is why in children it causes drowsiness. And while we don't have exact data on younger infants and exact data on, you know, just using it a few times here and there, because of what I just mentioned, I generally tend to avoid using Benadryl unless really necessary and go for one of the newer medications instead.

Melanie Cole, MS: Okay. We're learning so much now, sticking with stuffy nose and congestion for a minute. There are other things, topical and things like Robitussin that can help with that chest congestion or stuffy nose and some of them do a lot of things, so they would seem to counteract each other. Some are for cough and congestion, but you want the cough to clear the congestion, but they're a cough suppressant. You get where I'm going with this. So, a lot of these kind of counteract each other, but we feel like they're going to help our child be more comfortable. And then, there's the things like Afrin that you just squirt up their nose, but I hear you're not supposed to use those for more than a couple of days as well.

Nikhil Menon, MD: I totally agree. And I think I see a lot of parents of young children and all they want is for their child to feel better. So, this is a tough question to answer. And you're right, sometimes it can feel like you're chasing yourself in a circle. But generally, for children younger than something like six years old, we really don't recommend doing any medications like Robitussin or cough medicine, or even the nose sprays like Afrin. This is because we just don't have that much data on how effective and safe they are in young children. So for kids in that age group, we just recommend doing things like supportive care. This can be steam showers, some saline spray or saline drops in the nose and nasal suction to remove mucus as needed. But for the most part, it's just a waiting game until things get better.

There are a couple other medications that can be used in older children and adolescents. We get a lot of questions about NyQuil and DayQuil, which really should only be used in children 12 years and older, and these are okay to use. But the important thing to know is that it's called Dayquil, but it actually contains a few separate things, including Tylenol. So if your child has a cold and fever, you cannot give both Dayquil and Tylenol, because they'll kind of get too much of the Tylenol component.

Melanie Cole, MS: That's a really important point that you just made. And a lot of parents don't know that because then you're doubling up on the same medication. Now, when we think of things like Afrin, Dr. Menon, there's also steam, VapoRub, nasal lavage and certainly putting like Aquaphor around their little chafed nostrils. What about things like that? Are we not supposed to use that? Do you like steam and VapoRub better?

Nikhil Menon, MD: I generally like the non-medicated treatments better for young children. So yes, I think in general, steam, VapoRub are perfectly fine. For older kids, you can use Afrin for a couple of days. But the problem with Afrin is that, while it's a very good medicine, it has a rebound effect when you stop using it if you use it for a long time. So if you use it for a couple of days, it's fine. But if you use it for a week or two and then stop, the congestion can actually come back even worse than it was when you started.

Aquaphor, though, you mentioned, is an amazing treatment that we have, and it works for just about everything. It is perfectly safe for babies of all ages and works really well for dry skin as well as some contact irritation and rashes.

There's another over-the-counter medicine that kind of goes hand in hand, which is hydrocortisone cream over-the-counter. This is a steroid cream that is anti-inflammatory. So, we use Aquaphor for dry skin, but if they have eczema or contact irritation, this hydrocortisone 1% can help quite a bit. I think cortisone 1% is not a very strong steroid medicine. And while we generally always give a lot of guidance about steroid creams and not using them too much in order to avoid side effects. I think it's perfectly fine to use this for a few days on even young children.

But a few tips. One is, if you're using it in a kid under a year old, generally best to ask one of us, your doctor, just to make sure that it's the right treatment for them. Second, I wouldn't use it more than twice a day. And the third thing is, if you need to use it for more than two or three days, I would get in touch with us as well, just to ensure that we're on the right track and treating the right thing.

Melanie Cole, MS: So, you're talking about rashes and right? Because babies get all these kinds of rashes. Little kids get rashes. I was told back long ago, my kids are older, to mix a little Aquaphor with the hydrocortisone, but I don't know that they made like 1% back then. Or is there a percentage we should look at and be wary of? Or is that okay to mix it with a little Aquaphor to bring it down a little bit?

Nikhil Menon, MD: In general, I think what they may have been doing was treating eczema, which is a condition that has both a dry skin component and inflammation. So usually for that, it's helpful to do both because the aquifer will treat the dryness and the cortisone will treat the inflammation. So, that's probably what was going on.

In general, the only cortisone cream you're going to find over-the-counter is the 1%, which is perfectly fine to use. If it's not enough, the doc can always prescribe a stronger one. The next one up is called 2.5%. So if that's the conversation that we're having, we can always talk more about which creams are better for which conditions. But in general, you don't have to be too wary of the percent creams that you're going to find over-the-counter.

Melanie Cole, MS: Now, I know we've covered a lot of these over-the-counter medications. Are there any, Dr. Menon, that we have not covered that you get questions about all the time?

Nikhil Menon, MD: I think we covered the typical ones that I get questions about, but there is one thing that I wanted to mention going back to our conversation on Tylenol and Motrin. We do get a lot of questions about whether it's safe to give these together, if you need to alternate or kind of how to give it if one is not treating the fever enough. So, I would say there's no need to alternate if one medication is sufficient to treat the fever. But sometimes, for some children, and especially with high fevers, giving one medication isn't enough. For example, if a fever is 104, and you give Tylenol, and it goes down to 102, 102 is better than 104, but it's not completely treated. So in those cases, it's perfectly safe to give the other medication or stagger them so that you're kind of giving double coverage. So, for example, if you have a 104, you treat it with Tylenol, it comes down to 102. You can then give Motrin even an hour later because they are completely separate medicines and safe to give on top of each other.

For some children, we know that they just get high fevers and need both in order to get the fever down. So in those cases, I do something called staggering, which means, for example, you could give Tylenol at noon, Motrin at 3:00, Tylenol at 6:00, and then Motrin at 9:00. So that way, they're getting something every three hours, but each medication is six hours apart from itself. So that way, you're not giving the same medication too close to each other.

Melanie Cole, MS: I know one that we forgot. Diarrhea. Yes, parents. So, kids get diarrhea, Dr. Menon. Of course, they do. Do we try and stop that? Of course, we're going to give Pedialyte or electrolyte beverages and you can reinforce that. I mean, in the old days, my parents gave us Kaopectate. Do we do that anymore? What are we doing?

Nikhil Menon, MD: We really don't. For just about every case of diarrhea in kids, as long as it is watery, meaning just kind of water coming out and no blood, and as long as they are able to stay hydrated, we really don't do anything. We just wait and let it run its course. And almost always, this resolves without doing anything additional.

 So my advice for parents is, with these cases, as long as the child can stay hydrated in order to make up for all the fluid that they're losing, it's okay to just kind of watch and wait. If they don't feel like eating solid food, that's okay too. Usually as soon as the diarrhea resolves, which is typically within seven days or so, they will make up for all the food that they didn't eat within a couple of days, we see it all the time.

Melanie Cole, MS: Yes, they definitely will. And we couldn't finish this podcast without talking about diarrhea, right?

Nikhil Menon, MD: Of course, we have to.

Melanie Cole, MS: How many times am I going to say that? Anyway, Dr. Menon, you're such a great guest. Do you have some final thoughts for parents on what you want them to know about over-the-counter medications and the most important thing, talking to our wonderful pediatricians, the gold standard of healthcare, and what you want us to know about that?

Nikhil Menon, MD: Yeah, I think over-the-counter medications are wonderful implements and can really be a lifesaver. Especially with fever and allergic reactions, they can make children feel so much better. But especially with kids, the dosing can be complicated. So, I would say please feel free to send your doctor a message just to confirm the dose if you're not sure, and just know that we're here to help.

Melanie Cole, MS: You certainly are. And thank you so much, Dr. Menon, for joining us. Our pediatricians are there to help us raise our kids happy and healthy and safe and you guys are just rock stars in my book. Thank you so much for joining us. And Weill Cornell Medicine continues to see our patients in-person as well as through video visits and you can be confident of the safety of your appointments at Weill Cornell Medicine.

That concludes today's episode of Kids Health Cast. We'd like to invite our audience to download, subscribe, rate and review Kids Health Cast on Apple Podcasts Spotify and Google Podcasts. And for more health tips, please visit weillcornell.org and search podcasts. And don't forget to check out Back to Health. We have so many interesting podcasts there as well. I'm Melanie Cole. Thanks so much for joining us today.

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