For the last week I have had a cold. I usually get one each winter. I have two kids in school and they bring home a lot of viruses. I also work in a hospital, which tends (for some reason) to have lots of sick people. Although this year I think I caught my cold while traveling.  I’m almost over it now, but it’s certainly a miserable interlude to my normal routine.

One thing we can say for certain about the common cold – it’s common. It is therefore no surprise that there are lots of cold remedies, folk remedies, pharmaceuticals, and “alternative” treatments. Finding a “cure for the common cold” has also become a journalistic cliche – reporters will jump on any chance to claim that some new research may one day lead to a cure for the common cold. Just about any research into viruses, no matter how basic or preliminary, seems to get tagged with this headline.  (It’s right up there with every fossil being a “missing link.”)

But despite the commonality of the cold, the overall success of modern medicine, and the many attempts to treat or prevent the cold – there are very few treatments that are actually of any benefit. The only certain treatment is tincture of time. Most colds will get better on their own in about a week. This also creates the impression that any treatment works – no matter what you do, your symptoms are likely to improve. It is also very common to get a mild cold that lasts just a day or so. Many people my feel a cold “coming on” but then it never manifests. This is likely because there was already some partial immunity, so the infection was wiped out quickly by the immune system. But this can also create the impression that whatever treatment was taken at the onset of symptoms worked really well, and even prevented the cold altogether.

What Works

There is a short list of treatments that do seem to have some benefit. NSAIDs (non-steroidal anti-inflammatory drugs), like aspirin, ibuprofen, and naproxen, can reduce many of the symptoms of a cold – sore throat, inflamed mucosa, aches, and fever. Acetaminophen may help with the pain and fever, but it is not anti-inflammatory and so will not work as well. NSAIDs basically take the edge off, and may make it easier to sleep.

Decongestants may also be of mild benefit. Antihistamines have a mild benefit in adults, but not documented in children. There are also concerns about safety and side effect in children. Overall, other than some TLC and NSAIDS (although not aspirin) parents should probably not give their children anything for a cough or cold. The benefit of antihistamines in adults is very mild and of questionable value. There is better evidence for antihistamines in combination with a decongestant, but the benefits are still mild. Nasal sprays are probably better than oral medication, and overall use a much lower dose. These treatments do not seem to have any effect on the course of the cold, but may relieve symptoms. Perhaps the best use of nasal spray decongestants is just prior to going to sleep, to reduce a post nasal-drip cough that can be very disruptive to sleep.

There is weak evidence for the use of hot liquids. There does not seem to be any advantage to chicken soup over other hot liquids, like tea. They may provide a symptomatic benefit in clearing the sinuses and loosening phlegm so that it can be cleared easier. Since this is a low risk intervention (just make sure the liquids are not too hot for small children), if it makes you feel better, go for it. There also may not be any advantage over just humidified air to help keep the membranes moist. Honey may be soothing, but there is no evidence of real benefit.

A neti pot looks like a small teapot with a thin spout that is meant to pour hot liquids up your nose to irrigate your sinuses. The evidence for the use of neti pots is mixed. Briefly – there is no evidence for their routine or preventive use, and in fact they may be counterproductive. However, they may be useful for acute symptoms of sinus congestion. The concept is actually simple and well established – irrigating an infected space to help wash out the germs and prevent impaction. There is probably no benefit to using a neti pot for a regular cold – unless you have significant sinusitis and feel that your sinuses are clogged. And again, this is probably no better than just moist air or hot liquids.

What Does Not Work

In short – everything else.

Over the counter (OTC) cough suppressants simply do not work and are not safe in children. If you have a serious cough, the kind that can cause injury, you need prescription medication (basically narcotics, like codeine). Also, in most cases using a cough suppressant makes no sense, especially in combination with an expectorant. You want to cough up the mucus and phlegm. If your cough is caused by a sore throat, take an NSAID. If it’s post nasal drip, treat the congestion as above. And if it’s severe, see your doctor. But don’t bother with OTC cough suppressants.

I have covered echinacea previously in detail – it does not work for the prevention or treatment of the cold or flu.

Vitamin C has been a favorite since Linus Pauling promoted in decades ago. But decades of research has not been kind to this claim. The research has failed to find a consistent and convincing effect for vitamin C in treating or preventing the common cold. For routine prevention, the evidence is dead negative. For treating an acute infection, there is mixed evidence for a possible very mild benefit, but this is likely just noise in the research.

What about homeopathic treatments? Since homeopathy is one big pseudoscientific scam, its products are nothing but water, and they don’t work for anything – I don’t need to go into more detail here.

Finally, there is some evidence that zinc or zinc oxide may reduce symptoms of a cold, but this evidence is mixed and unconvincing at present. At best the benefit is very mild (again, likely within the noise of such studies). Further, zinc comes with a nasty taste (something that also complicates blinding of studies) and many people may find this worse than symptoms it treats. Zinc oxide nasal sprays have been linked to anosmia (loss of smell, which can be permanent) and is certainly not worth the risk to treat a self-limited condition like the cold – even if they did work, which is unclear.

Conclusion

The common cold remains a difficult syndrome to treat effectively. In most cases it is best to just let the cold run its course. Limited use of NSAIDs and decongestants may be helpful. Otherwise, if there is an intervention that is risk free and makes you feel better, do it. We all need to feel comforted when we’re sick. But don’t waste your time or money on other medications, supplements, herbs, or other concoctions. There are also endless snake-oil products out there, too many to deal with here. A good default position is simply not to believe any product that claims to prevent or treat the common cold. And don’t be compelled by the anecdotal evidence of your neighbor’s cousin’s boss. Everyone thinks they have the secret to treating the cold, but no one does. It’s all placebo effect and confirmation bias.

Is unmedicated natural childbirth a good idea? The American College of Obstetrics and Gynecology (ACOG) points out that

There is no other circumstance in which it is considered acceptable for a person to experience untreated severe pain, amenable to safe intervention, while under a physician’s care.

It is curious when an effective science-based treatment is rejected. Vaccine rejecters have been extensively discussed on this blog, but I am intrigued by another category of rejecters: those who reject pain relief in childbirth. They seem to fall into 3 general categories:

1. Religious beliefs
2. Heroism
3. Objections based on safety

1. “In pain you will bring forth children” may be a mistranslation, and it certainly is not a justification for rejecting pain relief. Nothing in the Bible or any other religious text says “Thou shalt not accept medical interventions to relieve pain.” Even the Christian Science church takes no official stand on childbirth and its members are free to accept medical intervention if they choose.

2. The natural childbirth movement seems to view childbirth as an extreme sport or a rite of passage that is empowering and somehow enhances women’s worth. Women who “fail” and require pain relief or C-section are often looked down upon and made to feel guilty or at least somehow less worthy.

3. I’m not impressed by religious or heroic arguments, although I support the right of women to reject pain relief on the autonomy principle. What inquiring science-based minds want to know is what the evidence shows. Does avoiding medical treatment for pain produce better outcomes for mother and/or baby? It seems increasingly clear that it doesn’t. A new book, Epidural Without Guilt: Childbirth Without Pain, by Gilbert J. Grant, MD, helps clarify these issues.

Some of his points:

• Not providing adequate pain relief is inhumane.
• A large percentage of women who attempt childbirth without medication find the pain intolerable and end up asking for relief.
• Pain should be treated early, ideally before it even develops. The dentist doesn’t wait to inject Novocain until you feel the pain and complain.
• Excellent pain relief can be provided by epidurals with a high degree of safety. No other method is as good.
• There is no justification for outdated practices of delaying epidurals until cervical dilation is advanced or for stopping the epidural during the last stages of labor.
• Non-epidural analgesia is arguably less safe than epidurals.
• Many safety objections to epidurals are based on outdated information about older techniques. New epidural/spinal techniques use a combination of low-dose anesthetics and narcotics to abolish pain without interfering with muscle function. They do not prolong labor or increase the need for instrument-assisted deliveries, and they allow patients to control the dose and to get up out of bed and walk around.
• Epidural catheters can be left in place to better treat post-partum pain.
• If an emergency C-section becomes necessary, having an epidural in place can speed the preparations for surgery.
• Current data indicate that epidurals may actually speed up labor and have other health advantages.

He doesn’t deny that epidurals can cause adverse effects (from low blood pressure to spinal headaches). He discusses all reported complications of epidurals, explains them, and puts them into context with the adverse effects of other methods and with the adverse effects of unrelieved pain. Unrelieved pain during labor and post-partum has been shown to

• Cause stress responses that can reduce the baby’s oxygen supply
• Increase the risk of post-partum depression and post-traumatic stress disorder (PTSD)
• Interfere with breast-feeding
• Increase the risk of development of chronic pain conditions

A 2005 Cochrane review of studies comparing epidurals to other or no analgesia found a small increased risk of instrument-assisted delivery but no increase in the rate of C-sections, no effect on neonatal outcomes, and greater maternal satisfaction. The increased risk of instrument-assisted deliveries is not seen when newer epidural techniques are used.

In evaluating the literature, we must remember that epidurals have improved, and earlier studies looked at higher doses and less safe epidural practices.  Another confounder is that patients with problematic labors are more likely to ask for pain relief, so some of the complications previously attributed to epidurals might well have been due to other factors. I was particularly intrigued by one study he cited about a natural experiment. In 1993 the Department of Defense mandated that epidurals should be available on demand. At the Army hospital studied, the epidural rate went from 2% to 92%, but the rate of forceps deliveries and cesareans did not change.

Childbirth is a subject that seems to bring out the worst in strongly opinionated people. When I last checked Amazon.com, there were 4 reader reviews of this book. One was a gushing 5-star testimonial by a patient and friend of the author and the other three were 1-star emotional attacks on him for allegedly presenting inaccurate information and having a self-serving agenda for financial benefit. In reality, his information is accurate, is supported by the literature, and his conclusions are echoed by the ACOG and by a Clinical Therapeutics review article in the New England Journal of Medicine.

In my opinion, it is unconscionable to let patients suffering from severe pain go untreated unless there is compelling evidence that not treating pain results in improved health outcomes. It is even more unconscionable for ideologically motivated people to influence a patient to feel guilty about accepting pain relief. A typical natural childbirth website tells women that if they try but can’t stand the pain, they shouldn’t feel bad about asking for medication. The very fact that they felt compelled to say that is an admission that some women do feel bad. Alarmist midwifery websites ask “Why are so many women taking dangerous drugs during labor?” They  exaggerate the dangers of epidurals, referring to doctors as “drug pushers.” They tell women they should “embrace the full pain of childbirth.”

Novocain is a potentially dangerous drug, but can you imagine a dentist telling a male patient to “man up” and have a root canal procedure without any anesthetic?  Because it will be safer? Because embracing the pain will be empowering?

A double standard? Misogyny? Ideology? The “natural fallacy”? Gullible acceptance of anti-establishment myths and misconceptions? Whatever is going on, Dr. Grant offers a science-based corrective. He provides complete and accurate information in an accessible format so that pregnant women can understand and give informed consent. Some will cry “bias” and “cui bono” since he is an obstetric anesthesiologist, but I think his presentation is fair and supported by the published evidence. Is he motivated by money and self-justification, or is he a good doctor who is sincerely concerned for the best interests and comfort of his patients? What’s wrong with aspiring to give all your patients a pain-free birth experience using the safest possible science-based state-of-the-art methods?

Disclaimer:  I have no dog in this fight. As a family physician I delivered around 200 babies. I never gave an epidural (because I was not taught how), but I received one for my first baby.  For my second baby, epidurals were not available and I was given a paracervical/pudendal block. Both methods worked.