What is the recommended treatment for a cough in a child under 2 years of age?

Anticough Medications for Children Under 2 Years of Age

Over-the-counter cough and cold medications should NOT be used in children under 2 years of age due to safety concerns, lack of efficacy evidence, and risk of serious adverse effects including death. 1

Safety Concerns and Evidence

The FDA has issued public health advisories against using cough and cold medications in children under 2 years due to significant safety concerns:

• Reports of infant deaths associated with these medications 1
• Estimated 1,519 children under 2 years treated in emergency departments for adverse events related to cough and cold medications during 2004-2005 1
• No established safe dosing recommendations for this age group 1
• Limited evidence of effectiveness in this population 2

Recommended Approach for Cough in Children Under 2 Years

For Acute Cough:

1. "Wait, watch, review" approach is recommended for acute cough in young children 2
2. Supportive care measures should be provided:
   • Adequate hydration
   • Humidity (cool mist)
   • Nasal saline drops for congestion
   • Gentle suctioning for infants

For Chronic Cough (>4 weeks):

When a child under 2 years has a persistent cough lasting more than 4 weeks, a systematic diagnostic approach is recommended 3:

1. Determine if cough is specific or non-specific:

   • Specific cough: Associated with other symptoms suggesting underlying disease
   • Non-specific cough: Dry cough without specific pointers 3

2. Basic investigations for chronic cough:

   • Chest radiograph (recommended for all children with chronic cough) 3
   • When appropriate, other tests based on clinical presentation 3

3. Management based on cough characteristics:

   • For wet/productive cough without specific pointers: Consider 2-week course of antibiotics targeting common respiratory bacteria (S. pneumoniae, H. influenzae, M. catarrhalis) 3
   • For dry cough without specific pointers: Watch, wait and review approach 3

Common Causes of Chronic Cough in Young Children

The most common causes in children under 2 years include:

• Protracted bacterial bronchitis 4
• Post-infectious cough 4
• Tracheobronchomalacia 4
• Foreign body aspiration 4
• Less commonly: bronchiectasis, asthma, gastroesophageal reflux 4

Important Cautions

• Never use cough suppressants in children under 2 years - cough is a protective mechanism 4
• Parents often request medications for symptomatic relief, but should be educated about:
  • Expected duration of illness
  • Risks of over-the-counter medications
  • Appropriate supportive care measures 2
• Many parents remain unaware of FDA guidelines - a survey showed only 31% of caregivers were aware of recommendations against using cough medications in children under 2 years 5

When to Refer

Consider referral to a specialist when:

• Cough persists despite appropriate initial management
• Specific pointers suggest underlying disease (e.g., digital clubbing, coughing with feeding)
• Chest radiograph shows abnormalities
• Recurrent episodes of wet cough requiring antibiotics 3

Remember that cough suppression is rarely indicated in childhood, and the focus should be on identifying and treating the underlying cause rather than merely suppressing the symptom 4.