New Delhi: In Madhya Pradesh, grief-stricken families are haunted by how a mild cough and cold in their children spiralled into fatal kidney failure, raising urgent questions about the safety and necessity of cough syrups for young children.
A 2024 meta-analysis published in the Medical Journal Armed Forces India found that nearly 64 per cent of Indians self-medicate, with the highest rates reported in northern India. Cough and cold were among the most common ailments treated without prescription, often using cough syrups and antipyretics bought directly from local chemists.
The study noted that most people relied on pharmacists, old prescriptions, or family advice rather than doctors, citing financial constraints and unlimited access to healthcare. Researchers have shown that such widespread and regulated use of over-the-counter drugs poses a serious risk of overdose, misuse, diagnosis, and toxicity.
“Cough syrups are rarely necessary for children under the age of five,” paediatrician and allergy specialist at Sir Ganga Ram Hospital in New Delhi, Dr Dhiren Gupta, said. “Over-the-counter availability of unregulated medicines has worsened the risk.”
The Indian cough syrup market is set for strong growth. It is projected to rise from $262.5 million in 2024 to $743 million by 2035, at a CAGR of 9.92 per cent. Respiratory illnesses, pollution, and changing weather patterns are driving demand. Consumers increasingly prefer herbal, natural, and Ayurvedic formulations.
At least 23 children were killed after consuming Coldrif cough syrup in Madhya Pradesh, which was manufactured in Tamil Nadu’s Kanchipuram district. Drug regulators found the presence of DEG, a toxic industrial solvent. Now, the manufacturing license of the firm has been cancelled, and state governments have also placed a ban on the sale and purchase of the alleged cough syrup. The incident prompted calls for strict regulatory measures in the pharmaceutical industry to prevent such tragedies in the future.
Medicine or quackery?
A cough in a child is rarely an illness by itself. For Dr. Dhiren Gupta, it is a symptom that needs diagnosis, not suppression.
“Cough is a protective reflex. If there is mucus in the lungs, it must come out. Suppressing it without knowing the cause can be harmful,” Gupta said.
According to him, doctors must first identify whether a cough is dry, wet, or caused by an underlying issue: asthma, reflux, or post-nasal drip. It should be treated by doctors. They should not be reaching for syrups.
Most cough syrups, he said, are cocktails of multiple drugs: expectorants, suppressants, decongestants, and bronchodilators. They often work against one another. While some ingredients sedate, others irritate.
“When you combine these drugs, it is quackery,” he said.
For children under the age of five, Dr. Gupta was firm. “They don’t need cough syrups. At most, give honey or steam at home. If the cough persists, doctors need to find the cause; they don’t have to mask it.”
And, for older children, a syrup may occasionally help, but only when prescribed in specific doses, and for a clear reason, he said.
Dr. Kafeel Khan, a paediatrician who became popular in 2017, during the Gorakhpur tragedy of oxygen cylinders, doesn’t mince words when it comes to the pros and cons of cough syrup for children.
“Whether you treat a cough or not, it usually goes away in a week. Cough syrups don’t shorten the duration,” he said.
According to him, cough syrup is often nothing more than sedatives in disguise. They make the child drowsy, the parents happy, and the doctor looks effective.
“It’s not treatment, it is an illusion,” he said. The problem, he said, is deep-rooted: parents in rural areas insist on medicine for every cough, and doctors are pressured by both expectations and pharmaceutical marketing, and end up obliging.
Dr Anand Phadke, a veteran community physician and a longtime advocate for rational pharmacology, and a member of All India Drug Action Network, has been sounding the alarm on the dangers of irrational cough syrup for decades. He said that most cough syrup in the market is an “all-in-one” formula. They contain multiple active ingredients that often contradict each other.
Suppressants act on the brain to stop the cough reflex, while expectorants work to expel mucus from the lungs, he said. Combining the two, Phadke warned, can lead to unnecessary medication and side effects, and often fails to address the patient’s actual symptoms.
Children are especially at risk, he stressed.
Dr Khan talked about the combinations that are banned: Chlorpheniramine + Codeine phosphate + Menthol, Dextromethorphan + Chlorpheniramine + Ammonium chloride + Sodium citrate + Menthol, and Ambroxol + Terbutaline + Ammonium chloride + Guaiphenesin, Cetirizine + Phenylephrine, and Cetirizine + Paracetamol + Phenylephrine, among others, were prohibited more than a decade ago for their potential to harm children. Yet, they remain on pharmacy shelves, he said.
“Children up to 2-4 years of age have a delicate physiology. Even a small dose of medicine can affect them,” Dr. Phadke said. Some anti-cough medicines can have central effects on the brain. They can trigger acidity. And, overdosing can become dangerous.
Dr Vandana Prasad, a community paediatrician and technical advisor with the Public Health Resource Society, has seen expectations of ‘medicine for every ailment’ drive both demand and its misuse.
She dismissed popular myths around syrup forms.
“It’s not about tablets, it is about chemicals. And children under age 3 or 5 can’t swallow tablets,” she said. While for sugar and alcohol content, she said alcohol content in syrup has drastically reduced, and while sugar remains a common addiction, it is often necessary. “If you remove sugar, the syrup becomes difficult to swallow, the child will gag or vomit,” she said.
Even a 2025 hospital-based community study conducted by JSS Medical College in Mysuru found that 46 per cent of parents indicated their under-five children used over-the-counter drugs. Among them, 75 per cent used cough syrup, followed by antipyretics (72 per cent), and antibiotics (58 per cent).
The study noted that urban parents and homemakers were more likely to self-medicate than others. The researchers warn that this pattern of unsupervised OTC use, especially for offences in very young children, reflects both gaps in healthcare access and a dangerous normalisation of self-treatment in India.
There are multiple flavours available for cough syrups, like Tulsi, orange, mango, honey, lemon, and strawberry. A research study titled Sugar content, cariogenicity, and dental concerns with commonly used medications, from February 2015 published in The Journal of the American Dental Association, said that patients who are required to take multiple doses per day of these sugar-containing oral liquid medications may be at increased risk for caries and associated oral health consequences.
Also read: ‘Feeding cough syrup seems like Russian roulette’—new book exposes drug regulation in India
An Indian obsession
By contrast, India has repeatedly struggled with the same problem. Dr Pankaj Hari, Head of the Department of Pediatrics, and a nephrologist at AIIMS, New Delhi, said that the deaths in Madhya Pradesh are not caused by cough syrup itself, but it has highlighted Indians’ cough syrup obsession.
The US Food and Drug Administration (FDA) strongly advises against giving over-the-counter cough and cold medicines to children under the age of four, warning that they can cause serious and potentially life-threatening side effects. Most colds in children resolve on their own, and the medications do not speed up the recovery.
Dr Hari said the traditional cough syrups are designed to be safe, but if a child consumes an entire bottle, the medicine is likely to be lethally toxic.
“This may cause deep sedation if the patient has overdosed, but they do not cause kidney failure; the real killer is the contamination,” Dr. Hari said.
Pharma-doctors nexus
“Doctors often prescribe these shortcuts because people want quick relief instead of consulting physicians. Pharma companies also propagate misleading information, and regulatory oversight is weak,” Dr. Phadke added.
Meanwhile, Dr. Khan said developed countries have stopped using the combination cough syrup. “In the US or UK, they don’t prescribe cough syrup at all,” he said.
In India, however, the nexus between pharma companies and doctors has kept the syrup culture alive. Pharma companies push fixed-dose combinations without any scientific evidence, and the doctors rarely question them. This obsession with syrup has become cultural.
(Edited by Ratan Priya)