The conventional remedies are useless, so do herbal concoctions offer any relief?
Winter ills come in a variety of guises, none more irritating than a cough that won 't go away. Mounting evidence suggests that conventional cough suppressants are ineffective and may even be dangerous. But what can you do if you have a sore throat and you can 't stop coughing?
Doctors often recommend over-the-counter (OTC) cough mixtures, despite the lack of evidence that they work. A recent review (BMJ, 2002; 324: 329-31) involving 2166 individuals found that, in 60 per cent of studies, cough medications were ''no better than placebo''. In the remainder, say the researchers, positive results were small and ''of questionable clinical relevance''.
Conventional and OTC treatments are usually aimed at suppressing symptoms, and many are of questionable safety and value. Codeine doesn 't suppress coughs, but can produce constipation. Some mixtures contain alcohol, and many contain sugar - those that don 't may contain sugar substitutes and sweeteners, such as mannitol and xylitol, which can cause stomach upsets.
Of genuine concern is the use of dextromethorphan (DXM) and phenylpropanolamine (PPA). DXM is a semisynthetic narcotic related to opium, a hallucinogen abused to get a 'poor man's high'. Its raft of adverse effects includes (but isn't limited to) confusion, impaired judgement and mental function, blurred vision, slurred speech, loss of coordination, tremors, dizziness, nausea, abdominal pain, vomiting, paranoia and high blood pressure. DXM is also a suspected cause of liver damage and a cause of birth defects in animal studies (Pediatr Res, 1998; 43: 1-7), which some speculate may also be true in humans.
PPA (ephedrine) is a common ingredient in diet drugs and cough/cold medicines. In one study, any product containing PPA increased the risk of stroke in women by more than three times (N Engl J Med, 2000; 343: 1826-32). As the final straw in more than a decade of studies into the adverse effects of PPA, the US Food and Drug Administration has now asked drug companies to stop selling products containing PPA. Yet, in the UK, it is still widely available in cold remedies. Parents should be mindful that PPA has never been licensed for use in children under the age of six.
Better, safer options
A number of herbs have traditionally been used for cough due to colds, bronchitis or other mild conditions, but only a few studies have examined their effectiveness. Among those shown to have some cough-relieving actions are marshmallow (Pharmazie, 1992; 47: 224-6), drosera or sundew (Schilcher H, Phytotherapy in Paediatrics, Stuttgart: Medpharm Scientific Publishers, 1997: 38) and coltsfoot (Wichtl M, Bisset N, eds, Herbal Drugs and Phytopharmaceuticals, Boca Raton, FL: CRC Press, 1994).
Thyme has a long history of use in Europe for dry, spasmodic coughs as well as bronchitis (Leung AY, Foster S, Encyclopedia of Common Natural Ingredients Used in Food, Drugs, and Cosmetics, NY: John Wiley & Sons, 1996: 492-5). Alone or in combination with herbs such as drosera, thyme continues to be a commonly used herb for dry, spasmodic coughs as well as whooping cough (Weiss RF, Herbal Medicine, Beaconsfield, UK: Beaconsfield Publishers, 1988: 208-9). Unlike some herbs, thyme appears to be safe for use by even young children.
Liquorice is sometimes used as an expectorant and antispasmodic. Similarly, aniseed, a herb with a liquorice-like flavour, can help to gently relieve spasmodic coughs (Weiss RF, op cit, 1985: 203-4).
Slippery elm contains a gelatine-like substance (mucilage) that soothes the mucous membranes of the throat and, thus, may be useful for cough. Usnea and coltsfoot have similar actions.
Other traditional herbals for cough include wild-cherry syrups, bloodroot, catnip, comfrey (aerial parts), horehound, elecampane, mullein, lobelia, Ephedra, hyssop, liquorice, mallow (Malvia sylvestris), red clover, ivy leaf, pennyroyal (Hedeoma pulegioides, Mentha pulegium), onion (Allium cepa), olive leaf and plantain (Plantago lanceolata, P. major). None of these has been investigated in clinical trials.
We reviewed the ingredients of a range of natural cough medicines to see if they contained known active herbs, and also to see what else they contain. We found no clear trend of using any particular herb, although thyme, white horehound and hyssop seem to be equally popular. Drosera, in both its extract and homoeopathic forms, is also often used.
To get the best out of herbal cough mixtures, you need to identify the type of cough you have to find what remedy will best suit your needs. Dry cough, for example, needs a soothing mixture while a wet one can be aided by an expectorant.
Unless you are very well informed about herbs, choosing the right mixture may be a bit hit-and-miss and, by UK labelling laws, only those products with licenses can make any kind of therapeutic claim for their use. From the consumer 's point of view, this is unsatisfactory as many efficacious herbal products may therefore be overlooked simply because they lack product licenses and thus cannot state clearly what they are for.
Most of our test products used a sugar base since many of the herbs used just don 't taste nice; horehound, in particular, can be very bitter. As cough syrup is not taken in great quantities every day for weeks on end, the use of sugar rather than artificial sweeteners (which are of questionable safety) seems reasonable, and no points were lost for this. Those wishing to avoid sugar can use tinctures, such as Bioforce 's Ivy-Thyme Complex (alcohol base), Nature's Answer's Respitone Complex (glycerine base) or Potter's Catarrh Mixture No 127 (alcohol/ glycerine base).
To compare costs, we calculated how much 100 mL of each would cost. As each product is taken at different dosages, we also calculated how much it would cost to take the maximum dose every day.
Distributor: Nature's Answer
Price: lb7.45 (30 mL)
Ingredients: elecampane (Inula helenium) root, coltsfoot (Tussilago farfara) leaf, hyssop (Hyssopus officinalis) aerial parts, goldenseal (Hydrastis canadensis) root, bayberry (Myrica cerifera) bark and cayenne (Capsicum annuum) fruit; base: coconut glycerine and triple-filtered water
Coltsfoot has a long history of use for throat and respiratory conditions; the fresh plant is rich in mucilage, a gelatinous throat-soothing substance. However, this mixture is most likely an expectorant. Hyssop is an expectorant as is elecampane, which is also mildly antiseptic. Goldenseal is antimicrobial, but poorly absorbed in the gut, though a gargle with this mixture several times a day may prove useful for throat infections. Cayenne is similarly antimicrobial.
At lb24.83 per 100 mL, this was the most expensive product in our test. But because it is a tincture, the suggested dose is 0.5-1 mL daily, or 24.8 p/day, the cheapest in our survey. (In acute cases, the dose may be increased to 0.5-1 mL four times a day for no more than 10 days. This would set you back 99 p/day.)
Price: lb7.99 (50 mL)
Ingredients: 100 per cent fresh plant tincture; 100 g contains Hedera helix (ivy) 30 g, Thymus vulgaris (thyme) 25 g, Pimpinella saxifraga (lesser burnet) 25 g, Marrubium vulgare (white horehound) 10 g, Glycyrrhiza glabra (sweet root or liquorice) 10 g
Suitable for adults and children, this tincture contains ivy, which is antispasmodic, an expectorant and mildly sedative. Liquorice is an antiviral expectorant, demulcent, anti-inflammatory and immunostimulant. Lesser burnet is an antimicrobial diaphoretic (promotes sweating). White horehound is a strong, bitter, herbal expectorant long used for bronchitis and whooping cough.
This product would set you back lb14.98 for 100 mL but, again, it's a tincture. The label suggests 15 drops two or three times a day. By our calculations, 45 drops comes to 5 mL, so this would cost around 75 p/day.
Catarrh Mixture No 127
Price: lb8.06 (150 mL)
Active ingredients: liquid extracts of boneset, blue flag, burdock root and hyssop. Other ingredients: chloroform spirit, methyl hydroxybenzoate, tincture of capsicum, caramel, glycerine, water
Boneset (Eupatorium perfoliatum or Indian sage) fell out of fashion when doctors discovered aspirin, but is making a comeback. For Native and early American settlers, it was the first choice for colds/flu and fever. Blue flag (Iris) is used for immune support, but is also a powerful purgative, and burdock root has a tonic effect. Hyssop is an expectorant.
Potter's say this mixture is suitable for adults and children, but parents should note its alcohol/glycerine base and preservatives. To Potter 's credit, the adverse effects of these are noted on the label (but not on the others in this road test).
This remedy costs lb4.86 for 100 mL. The suggested use of 1 tsp (5 mL) three times daily will set you back 73 p/day.
Chest Mixture No 80
Price: lb6.23 (150 mL)
Active ingredients: liquid extracts of horehound, pleurisy root, senega; acid tincture of lobelia and acetum scillae. Other ingredients: syrup, glycerine, rectified spirit, methyl hydroxybenzoate, cubeb oil, tincture quillaia special, chloroform, fluid extract wild cherry, tincture Capsicum, anise oil, propyl hydroxybenzoate, water
Horehound, lobelia and pleurisy root are very powerful expectorants. Senega (snake root) is also a powerful expectorant and diaphoretic with a similar action to ipecacuanha, but much stronger. Acetum scillae, or vinegar of squill, is a very old remedy for bronchitis and coughs, and is a stimulant, expectorant and diuretic; quillaia (soap tree) is yet another expectorant. This aggressive mixture is not suitable for children.
Your 100 mL costs lb4.13. The suggested dose is 5 mL every three hours. Assuming a 15-hour adult day, you would be taking 5 tsp daily (25 mL), at a cost of lb1.03.
Price: lb4.60 (200 mL)
Active ingredients: aqueous extract and distillate from Thymus vulgaris (thyme), Pimpinella anisum (aniseed) and Marrubium vulgare (white horehound); aqueous extract of Althaea officinalis Rad (marshmallow root); homoeopathic potencies of Drosera (whole plant) 2X, Ipecac (root decoction) 1X and Pulsatilla (whole plant) 3X. Other ingredients: cane sugar, malt extract, ethanol
This anthroposophical remedy is mainly an expectorant and anti-infective due to the aniseed and thyme. Drosera, Ipecac and marshmallow are soothers, and marshmallow is also purported to be an immunostimulant. This relatively gentle formula is suitable for adults and children.
Although reasonably priced at lb2.63 for 100 mL, at the suggested dose of two 5-mL tsp every three or four hours - up to four doses daily - this costs lb1.05 every day.
Price: lb3.95 (100 mL)
Ingredients: Drosera rotundifolia in a base of raw, unrefined sugar, spruce extract, pear concentrate, honey and ivy extract
The active ingredient, Drosera rotundifolia (sundew), is a traditional remedy used for whooping cough. It is believed to have antispasmodic (to suppress coughing), anti-inflammatory and antibiotic properties.
This is a soothing cough syrup for adults and children and, like all syrups, is rather high in sugar. However, Bioforce gets credit for using fruit concentrates rather than refined sugars or sugar substitutes.
But this is expensive to use in quantity. Suggested use is 1-2 tsp (5-10 mL) two to four times daily - which would cost you from 37 p to a whopping lb1.48 a day.
Vegetable Cough Remover
Price: lb3.77 (100 mL)
Active ingredients: black cohosh, ipecacuanha, lobelia, pleurisy root, skullcap, liquid extracts of elecampane, horehound and hyssop. Other ingredients: Capsicum, skunk cabbage, valerian, anise oil, tincture myrrh, solid extract liquorice, treacle syrup, rectified spirit, methyl hydroxybenzoate, propyl hydroxybenzoate, chloroform microcrystalline cellulose, water. The active ingredients are expectorants, so this product is suitable for wet coughs. Black cohosh (buttercup family) is traditionally used as a general tonic and for respiratory disorders. Ipecacuanha is an expectorant; pleurisy root soothes bronchial spasm; elecampane is an antiseptic and expectorant; skullcap eases pain, calms anxiety and induces sleep (as does valerian).
Lobelia and skunk cabbage make this a potentially strong expectorant despite being reputedly for adults and children. Also, this has an alcohol base and contains preservatives.
Costing lb3.49 for 100 mL, this is an expensive product with a suggested use of two 5-mL doses three or four times daily. The maximum use will cost you lb1.40 a day.
Herbetom Pulm Respiratory Formula
Distributor: Bioserum UK
Price: lb12.95 (250 mL)
Ingredients: fructose syrup, aloe vera juice (10 per cent), aromatic plant extract comprising eucalyptus, thyme, Plantago and elder (10 per cent), beta-carotene preparation (2.5 per cent), propolis (0.5 per cent), pine bud extract
This odd mixture appears to be 77 per cent syrup. Of the other ingredients, eucalyptus, an antiseptic, expectorant and antispasmodic (relieves or prevents spasms and convulsions), is thought to be one of the best oils for bronchial conditions. Plantago (plantain) is an analgesic and anti-inflammatory. According to the British Herbal Pharmacopoeia, elder flowers provide therapeutic relief against flu and sinusitis (sinus inflammation). Beta-carotene is an antioxidant and immune-booster, though we don 't know exactly how much of it is in the mix.
The addition of aloe, however, warrants caution. Aloe serves no purpose in respiratory infections and is a purgative. Although this claims to be suitable for adults and children, you don 't want to add diarrhoea to your child's list of ills.
This product will cost you lb5.18 for 100 mL. The suggested dose of 10 mL three times daily will cost you lb1.55, the most expensive in our survey.
Sootha (Bryonia) Cough Syrup
Price: lb4.31 (150 mL)
Ingredients: 6C homoeopathic potency of Bryonia dioica in a base of natural honey, sorbitol, water, lemon juice and methylparaben
This is intended to be a soothing mixture for adults and children. Toxic in material doses, Bryonia dioica (wild hops) is widely used in homoeopathy to treat cough, though there is little evidence to show how good it is. If you have a dry, hacking, non-productive cough and a sore throat and/or symptoms such as irritability, difficulty swallowing and difficult, painful, quick respiration, this remedy may be of benefit.
Sootha costs lb2.80 for 100 mL. The suggested dose of 5 mL three times daily will cost you a moderate 42 p/day.