What is the recommended dose of codeine (opioid cough suppressant) for a 7-year-old with a persistent raspy cough?

Codeine Should Not Be Used for Cough in a 7-Year-Old Child

Codeine should not be used for cough in a 7-year-old child due to the potential for serious side effects including respiratory distress. 1

Why Codeine Is Contraindicated

The 2020 CHEST guidelines explicitly recommend against using codeine-containing medications for children with acute cough because of the significant safety concerns:

• FDA has restricted prescription opioid cough medications (including codeine) to adults ≥18 years only 1
• Codeine can cause serious adverse effects including respiratory depression 1
• There is potential for opioid toxicity, especially in children 2
• Some children are "ultra-rapid metabolizers" who convert codeine to morphine at a faster rate, increasing risk of serious side effects 3

Alternative Approaches for Managing Persistent Raspy Cough

First-line options:

• Honey - May offer more relief for cough symptoms than no treatment, diphenhydramine, or placebo 1
  • Note: Honey should only be used in children over 1 year of age due to botulism risk

Second-line options if appropriate:

• Dextromethorphan - Non-sedating alternative that has been shown to suppress acute cough 1
  • However, evidence for efficacy in children is limited

For persistent cough with possible asthma component:

• If risk factors for asthma are present, a short 2-4 week trial of inhaled corticosteroids (400 μg/day of beclomethasone equivalent) may be considered 1
• Child should be re-evaluated in 2-4 weeks

Important Clinical Considerations

Evaluation Before Treatment

• Persistent raspy cough warrants evaluation for specific causes before symptomatic treatment
• Assess for "etiological pointers" that might indicate a specific diagnosis requiring targeted treatment 1
• If non-specific cough doesn't resolve within 2-4 weeks, the child should be re-evaluated 1

Safety Concerns with OTC Medications

• OTC cough medications have little to no benefit in symptomatic control of cough in children 1
• Preparations containing antihistamines and dextromethorphan have been associated with adverse events 1
• Deaths from toxicity have been reported in young children 1

Pitfalls to Avoid

1. Don't prescribe based solely on parental pressure - Studies show physicians often prescribe medications based on perceived parental expectations 1

2. Don't assume codeine is safe because it was traditionally used - Recent evidence and regulatory actions clearly contraindicate its use in children under 12 years 2, 3

3. Don't continue ineffective treatments - If medications are used, they should be discontinued if no effect is seen within the expected timeframe 1

4. Don't forget environmental factors - Address environmental influences that may be contributing to the cough 1

The evidence is clear that codeine should not be used for cough in a 7-year-old child. Instead, focus on identifying the underlying cause of the persistent cough and consider safer alternatives like honey if symptomatic treatment is needed.