Winter is here!

Apotex: woman blowing nose

Pharmacists are a prime source of advice on treating common winter ailments such as cough and cold symptoms, says Leanne Philpott

Winter ills are typically managed through self-care but when it comes to pediatric patients, over-the-counter (OTC) cough and cold products are not recommended. This can leave many parents feeling helpless.

“What’s really hard for parents of children who are suffering from a cough or cold is not knowing what to do or where to turn and this is where pharmacists are a wonderful source of information,” says paediatrician Dr Deb Levy.

“The first approach is always to clarify the cause of the cough. If you’ve excluded asthma and reflux, for example, you can then reiterate that multiple studies have shown that cough syrups have no benefit in children but the potential side effects could cause harm.”

Edward Bell, professor of pharmacy at Drake University explains, “No controlled studies have shown [OTC cough and cold] products to be effective in children under 12 years of age. Efficacy has been assumed from adult studies. The theory was that if they’re effective in adults, they must be effective in children. However, this is not a valid assumption.

“Data from the FDA has shown that, especially in children younger than 5-6 years of age, [cough and cold products] can be dangerous; the younger the child, the greater the potential danger. The danger comes mainly from an increased potential for inappropriate use of these products, as the doses are small, the volume doses are small and it becomes easy for parents to make mistakes administering them; it is difficult to accurately measure small volumes, and as there are many products available OTC and as they often contain many ingredients, it is easy for parents to give products with similar ingredients, and thus too much drug is given.”

Non-pharmacological remedies for children

Non-pharmacological strategies that can help address symptoms of a cough or the common cold might include keeping the child hydrated, encouraging rest, avoiding passive cigarette smoke and using nasal saline.

Dr levy advises, “Saline spray or drops can be helpful in treating a post-nasal drip cough caused by the common cold or a blocked nose. I find the spray saline a better option, although children can resist both formulas; it’s important for parents to be relaxed when administering so that it’s more of a matter of fact situation as opposed to a stressful event.

“Running the bottle under hot water to warm the solution can also be helpful. Another way to assist with nasal secretion in children is through positional drainage. Lie the child on their tummy, either over the parent’s lap or the edge of a bed, with their head and chest angled down towards the floor.

“Keep them there for about five minutes, as long as they’re not resisting. This helps move the mucus and when they sit up get them to cough or older kids can blow their nose. This can be done before bed or during the day if you notice the child has lots of mucus.

“It’s completely harmless so parents can feel comfortable doing this at home. Older children can also sleep on a few extra pillows so their head is up and secretions aren’t pooling in their nose.”

She says non-medicated lozenges or even a lolly can help with symptoms affecting the throat. “Any kind of lolly that produces a lot of saliva does the same job as a lozenge. It thins secretions in the back of the throat.

“Honey has been demonstrated to be effective in controlled trials for cough. I recommend using the best quality Manuka honey you can find and making it into a syrup or a drink.

“Ideally you should mix it with some garlic or onions, but for children you can blend lemon with the honey and give them half a teaspoon or add it to some warm water for them to drink. It soothes the throat and there’s the added benefit that honey is a great antioxidant, as well as being antibacterial and antiviral.”

She says another simple and old-fashioned piece of advice is to drink lots of clear fluids. She adds, “Despite popular belief, there’s no evidence that avoiding cow’s milk will alter mucus production. If you have a lot of mucus in the throat and you drink cow’s milk it will stick to the mucus making your throat feel thicker, but it doesn’t actually increase mucus production.

“Ensure patients are eating a healthy diet with lots of fruits and vegetables, especially those that are high in vitamin A and C like citrus fruits and orange vegetables. Homemade chicken soup is old fashioned but studies have shown that it’s anti-inflammatory and helps with mucus production.”

She also highlights that in dry environments a vaporizer, used with or without aromatherapy oils, can be beneficial for breathing and inflammation.

Advice for adults

Consultant pharmacist John Bell advises, “Before recommending any symptomatic treatment to a customer, it’s important to confirm they haven’t been suffering their cold or flu symptoms for longer than two weeks. If they have, or they’ve become worse after the first week of symptoms, the customer should be referred to their doctor.

In all other cases, make sure your customer has realistic expectations about the likely duration and severity of the symptoms. For instance, most cold symptoms will last about a week; a dry cough could linger on for two or three weeks.

Janet Sluggett, research fellow at the Centre for Medicine Use and Safety, Monash University, says, “We know that colds are caused by viruses and symptoms will usually improve within ten days. Pharmacists can tackle some of the common misconceptions by providing education about the aetiology of the common cold and explaining that cough and cold preparations will not cure the underlying illness; at best, they may provide some symptom relief.

“As pharmacists, we understand the importance of talking with consumers about their medical history and concurrent medicines before making a recommendation. Decongestants can exacerbate other medical conditions so it’s important to consider co-morbidities, such as cardiac disease, diabetes, prostatic hypertrophy, closed-angle glaucoma, hyperthyroidism, and whether someone is pregnant, when deciding whether a decongestant product is the best option.”

Bell says, “There is a vast range of cold and flu products available in pharmacy. It’s understandable then, that many customers are confused and unsure what products are right for them.  

“Pharmacists and pharmacy assistants should recommend products specific to their customer’s symptoms to provide the best possible outcomes for their health. 

“Spending time with the customer and asking targeted questions will help ease their confusion over this category and help ensure you recommend the most appropriate treatment.

“A sore and swollen throat and, or as well as, difficulty swallowing usually signals the first and most problematic symptom of an upper respiratory tract infection (URTI). This can be best treated with an anaesthetic or anti-inflammatory lozenge, gargle or throat spray.

Cough mixture recommendations should be tailored to the type of cough the customer describes. Most brands will have options for the heavy, chesty cough and the dry, nagging irritating cough.”

He says it’s best to treat the symptoms that are most troublesome with single ingredient products. “Paracetamol or ibuprofen can be suggested for the aches and pains and a nasal decongestant for the blocked-up nose. Remember, the topical decongestants (drops and sprays) should be used for no longer than five consecutive days.

“We should make sure the customer knows what ingredients the product contains and what each ingredient is for. Warn customers about “double dipping”; remind them that they should not take other products with paracetamol or ibuprofen if these ingredients are already in the combination cold and flu product they’re taking.

“Check the suitability of cough and cold products for women who are pregnant or breastfeeding. Also check whether there are likely to be any possible interaction problems if the customer is taking other medicines.

“Importantly, pharmacists must be aware of, and when appropriate make patients aware of, red flag symptoms; these include wheezing, shortness of breath, blood in the sputum, very high temperature and night sweats.”

Capitalising on the category

Norman Thurecht from Pitcher Partners says, “Outperformance in business requires extreme focus. That means knowing your business and understanding the customer’s wants, desires, needs and trends.”

However, Pitcher Partners’ research data (retail sales, retail stock and customer numbers) averages over a three-year period show significant missed opportunity in retail sales during the winter months of June, July and August.

“If we just look at one category, cold and flu, we can see in our category data that in any given year, 45% of the category sales fall in the four months from June to September. Yet, as the customer traffic in the pharmacy peaks the average retail sale in the cold and flu category declines,” says Thurecht.

He puts this down to any or all of the following reasons:

  1. Increased customer traffic reflects higher script volume, which can cause more staff to be engaged in the dispensary process;
  2. The stores are not laid out nor designed to help the customer self-select in the retail environment;
  3. There is a skills shortage in the pharmacy and staff cannot manage the customer based on multiple product solutions;
  4. Stock mix is not managed up and down in the categories based on seasons enough to influence customer’s purchasing activity.

“Customers are getting what they ask for but there’s no evidence of selling up, except in March. This high point of the average retail sale is about $16.30 in the cold and flu category. Yet if we think about the products in the category, this is actually quite low.

“In my view the average sale should be around $18 plus. Then there is the opportunity of additional items to manage the causes not just treat the symptoms. For example, the customer could be offered echinacea and vitamin C and/or zinc plus decongestant and/or nasal spray plus an inhaler or humidifier.

“What is clearly apparent from the best performing stores is the considerable planning that management puts into not only buying the right stock at the right price, but also the placement, promotion and ultimately the staff training and engagement on the condition so that when the customer enters the store during those busy months, they can get what they need.”

Andrew Pattinson, general manager at Instigo adds, “Through marketing and communication you need to position an entire solution for the category in eye of the consumer. They’re not coming in just for a product; they’re coming in for a solution to a problem. And that’s a multi-faceted solution that could involve the core product as well as a preventative product.

“Certainly, when it comes to coughs and colds, there’s the opportunity to treat, prevent and possibly provide an absence from work certificate. Data shows that this is something that’s really valued by customers. You can take what could be a low-margin sale and change it in to a much higher solution-based sale that’s going to meet the needs of the consumer.”

This article was originally published in the June 2017 print issue of AJP.

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