What medications are recommended for treating cough in pediatric patients?

Medications for Pediatric Cough Management

Over-the-counter (OTC) cough and cold medications should not be used in children under 4 years of age due to lack of efficacy and potential serious side effects including significant morbidity and mortality. 1, 2

Age-Based Approach to Cough Management

Children Under 4 Years

• Avoid all OTC cough medications including cough suppressants, antihistamines, and combination products 1, 2
• Safe interventions include:
  • Adequate hydration to thin secretions 2
  • Nasal suctioning and saline drops for nasal congestion 2
  • Humidification of air 2
  • For children >12 months: honey 2.5-5 ml (½-1 teaspoon) as needed 2
    • Never give honey to infants under 12 months due to risk of botulism 2

Children 4-6 Years

• Continue to avoid OTC cough medications 1, 2
• Diphenhydramine is specifically labeled as not for use in children under 6 years 3
• Focus on supportive care as described above

Children 6-12 Years

• Approach should be primarily etiologic rather than symptomatic 1
• If medication is deemed necessary:
  • Diphenhydramine may be used at 10 mL (25 mg) every 4-6 hours 3
  • However, antihistamines have minimal to no efficacy for cough relief 2

Children >12 Years

• Diphenhydramine 10-20 mL (25-50 mg) every 4-6 hours if needed 3
• Dextromethorphan may be considered for cough suppression 4

Etiologic Approach to Chronic Cough

For children with cough lasting >4 weeks:

1. Identify underlying cause rather than treating symptomatically 1

2. For nonspecific cough with asthma risk factors:

   • Consider a 2-4 week trial of beclomethasone (400 μg/day) or equivalent budesonide 1, 2
   • Re-evaluate in 2-4 weeks 1
   • Discontinue if no improvement 1

3. For wet/productive cough without specific diagnosis:

   • Consider 2-week course of antibiotics targeted to common respiratory bacteria 2
   • Re-evaluate after 2 weeks 2

4. For cough related to GERD:

   • Follow GERD-specific guidelines 1
   • Acid suppressive therapy should not be used solely for chronic cough 1

Important Cautions

• Codeine-containing medications should be avoided due to risk of respiratory distress 2
• If medication trial doesn't work within expected timeframe, discontinue and reconsider diagnosis 1
• Environmental factors:
  • Identify and eliminate tobacco smoke exposure 1
  • Address other environmental triggers 1

Monitoring and Follow-up

• Re-evaluate children with cough within 2-4 weeks 1, 2
• Watch for emergence of specific etiologic pointers 1
• Seek immediate medical attention for warning signs: difficulty breathing, high fever, cyanosis, lethargy 2

The evidence consistently shows that symptomatic treatment with OTC medications carries risks that outweigh benefits in young children, and treatment should focus on addressing underlying causes rather than suppressing the cough symptom itself.