What are the recommended treatments for cough in toddlers?

Recommendations for Cough Treatment in Toddlers

Over-the-counter cough and cold medications should not be used for treating cough in toddlers as they have not been shown to be effective and may cause serious side effects. 1, 2

Evaluation and Classification

When evaluating cough in toddlers, it's important to classify the cough based on duration:

• Acute: <2 weeks
• Subacute: 2-4 weeks
• Chronic: >4 weeks 2

Key assessment points:

• Presence of specific cough pointers (digital clubbing, chest pain, failure to thrive)
• Character of cough (wet vs. dry)
• Associated symptoms (fever, wheeze, feeding difficulties)
• Duration of symptoms
• Response to previous treatments

Treatment Recommendations

For Acute Cough (Most Common in Toddlers)

1. Supportive Care

   • Adequate hydration
   • Humidification of air
   • Saline nasal drops for nasal congestion 2

2. Honey

   • For children >1 year: honey may offer more relief for cough symptoms than no treatment, diphenhydramine, or placebo 1
   • Dosage: 2.5-10 ml (0.5-2 teaspoons) as needed
   • CAUTION: Never give honey to infants under 12 months due to risk of botulism

3. Avoid Medications

   • Do not use over-the-counter cough suppressants or cold medicines 1, 3
   • Avoid codeine-containing medications due to potential for serious side effects including respiratory distress 1
   • Dextromethorphan and diphenhydramine have not shown significant benefit in children 1, 3

For Persistent/Chronic Cough (>4 weeks)

1. Further Evaluation

   • Chest radiograph should be performed 1, 2
   • Re-evaluate for emergence of specific etiologic pointers 1

2. Specific Conditions

   a. Suspected Asthma/Reactive Airways

   • For children with risk factors for asthma: Consider a 2-4 week trial of inhaled corticosteroids (400 μg/day beclomethasone equivalent) 1, 2
   • Re-evaluate in 2-4 weeks to assess response

   b. Protracted Bacterial Bronchitis (PBB)

   • If wet/productive cough persists: Consider 2-week course of antibiotics (amoxicillin as first choice) 2, 4
   • Extend for additional 2 weeks if cough persists

   c. Gastroesophageal Reflux Disease (GERD)

   • Only treat when GI symptoms are present 1, 2
   • Do not use acid suppressive therapy solely for chronic cough 1
   • For formula-fed infants with GERD: Consider reducing feed volumes, using feed thickeners, or hydrolyzed milk formula 1
   • For breastfed babies with GERD: Alginates may be tried 1

   d. Obstructive Sleep Apnea (OSA)

   • If suspected, manage according to sleep guidelines 1

Follow-up and Referral

• Re-evaluate within 2-4 weeks if cough persists 1, 2
• Consider referral to a pediatric pulmonologist if:
  • Cough persists despite appropriate management
  • Specific concerning features are present (failure to thrive, recurrent pneumonia)
  • Diagnostic uncertainty exists 2

Common Pitfalls to Avoid

1. Assuming adult causes apply to children

   • Etiologies of chronic cough in children differ significantly from adults 1

2. Empirical treatment without proper evaluation

   • Avoid treating without identifying specific cough pointers 1, 2

3. Prolonged medication trials

   • If no response is seen within the expected timeframe, medications should be discontinued 1

4. Overlooking foreign body aspiration

   • Always consider this possibility in toddlers with sudden onset cough 5, 4

5. Ignoring environmental factors

   • Environmental tobacco smoke exposure should be determined and cessation advised 1

Remember that most acute coughs in toddlers are self-limiting viral illnesses that resolve with supportive care. The focus should be on identifying concerning symptoms that require further evaluation rather than suppressing the cough itself.