What are the treatment options for cough in a pediatric patient with a suspected viral illness?

From the Guidelines

For a pediatric patient with a suspected viral illness causing cough, I recommend starting with non-pharmacological approaches such as ensuring adequate hydration, using a cool-mist humidifier in the child's room, and offering honey (1/2 teaspoon for ages 1-5 years, 1 teaspoon for ages 6-11 years) for symptomatic relief in children over 12 months of age, as suggested by various guidelines 1. Honey should never be given to infants under 1 year due to the risk of botulism.

Key Considerations

• For children over 4 years, over-the-counter medications like dextromethorphan (dose based on age: 4-6 years: 2.5-5 mg every 4-6 hours, 6-12 years: 5-10 mg every 4-6 hours) may provide some relief, but evidence for their effectiveness is limited 1.
• Avoid using codeine or hydrocodone-containing cough suppressants in children due to safety concerns, as emphasized in the guidelines 1.
• Antihistamines, decongestants, and combination cold medicines are generally not recommended for young children, as stated in the guidelines 1.
• Most viral coughs are self-limiting and resolve within 1-2 weeks, hence the focus should be on symptom management while the child's immune system fights the viral infection.

When to Seek Medical Attention

• Parents should seek medical attention if the child has difficulty breathing, persistent high fever, worsening symptoms after initial improvement, or if the cough persists beyond 2-3 weeks, as these could be indicative of a more serious underlying condition 1.
• The management of chronic cough in children should be based on etiology, and there is little evidence for using medications for the symptomatic relief of cough, as noted in the guidelines 1.

Additional Recommendations

• In children with chronic cough (> 4 weeks) after acute viral bronchiolitis, the cough should be managed according to the CHEST pediatric chronic cough guidelines, which include the evaluation for the presence of cough pointers and the use of 2 weeks of antibiotics targeted to common respiratory bacteria and local antibiotic sensitivities, as suggested by the guidelines 1.
• For children with chronic cough unrelated to an underlying disease and without any specific cough pointers, a 2-week course of antibiotics targeted to common respiratory bacteria and local antibiotic sensitivities is recommended, as stated in the guidelines 1.

From the FDA Drug Label

Warnings Do not use if you are now taking a prescription monoamine oxidase inhibitor (MAOI) (certain drugs for depression, psychiatric or emotional conditions, or Parkinson’s disease), or for 2 weeks after stopping the MAOI drug. If you do not know if your prescription drug contains an MAOI, ask a doctor or pharmacist before taking this product Allergy Alert: Contains sodium metabisulfite, a sulfite that may cause allergic-type reactions. Ask a doctor before use if you have • chronic cough that lasts as occurs with smoking, asthma or emphysema • cough that occurs with too much phlegm (mucus) Stop use and ask a doctor if • side effects occur. You may report side effects to FDA at 1-800-FDA-1088 • cough lasts more than 7 days, cough comes back, or occurs with fever, rash or headache that lasts. These could be signs of a serious condition. If pregnant or breast-feeding, ask a health professional before use. Purpose Cough suppressant

For a pediatric patient with a suspected viral illness, dextromethorphan (PO) can be used as a cough suppressant 2 2.

• The patient should be monitored for side effects and the cough should not last more than 7 days.
• If the cough persists, returns, or is accompanied by fever, rash, or headache, the patient should be evaluated by a doctor, as these could be signs of a serious condition.
• It is also important to ask a doctor before use if the patient has a chronic cough or a cough with excessive phlegm.

From the Research

Treatment Approaches for Cough in Pediatric Patients with Suspected Viral Illness

• The management of acute cough in children is based on a "wait, watch, review" approach, as most cases are self-limiting and result from expected childhood viral illnesses 3.
• Clinicians should educate parents on expected illness duration, the risks of using over-the-counter medications, and discuss safe, supportive care measures to alleviate the child's discomfort 3.
• For pediatric patients with COVID-19, supportive care alone is suggested for the overwhelming majority of cases, with antiviral therapy considered only for severe or critical disease 4.
• The use of antivirals, such as remdesivir, should be weighed against the risks and benefits, and preferably used as part of a clinical trial if available 4.

Symptomatic Relief for Acute Cough

• Cough medications offer no symptomatic relief for acute cough in children, and their use is inappropriate in young children due to potential side effects and adverse reactions 3.
• Non-sedative agents, such as levodropropizine, and natural compounds, including honey, glycerol, and herb-derived components, may be used to safely manage acute cough in pediatric patients 5.
• Saline nasal irrigation or nebulizing aerosol may help reduce symptoms of seasonal coronaviruses and other common cold viruses, and may be a useful add-on to first-line interventions for COVID-19 6.

Fever Management in COVID-19

• The use of ibuprofen to treat fever in COVID-19 may be associated with worse outcomes, as it may hinder the benefits of a fever response 7.
• Acetaminophen may be a safer alternative for fever reduction in pediatric patients with COVID-19, although further studies are needed to confirm this 7.