What is the recommended management for a child under 2 years old with a very chesty cough?

Management of Chesty Cough in Children Under 2 Years Old

For children under 2 years old with a chesty cough, avoid over-the-counter cough medications and focus on identifying the underlying cause through specific clinical evaluation, as these medications offer no symptomatic relief and may cause harmful side effects. 1, 2

Initial Assessment

When evaluating a child under 2 years with a chesty (productive/wet) cough, consider:

• Duration of cough: acute (<2 weeks), subacute (2-4 weeks), or chronic (>4 weeks) 3, 1
• Specific cough pointers:
  • Feeding difficulties
  • Failure to thrive
  • Abnormal lung examination
  • Recurrent pneumonia
  • Family history of chronic lung disease
  • Digital clubbing
  • Immunodeficiency signs 1

Management Based on Duration

For Acute Cough (<2 weeks)

• Adopt a "wait, watch, review" approach as most cases are self-limiting viral infections 2
• Provide supportive care:
  • Adequate hydration
  • Humidity (cool mist humidifier)
  • Nasal saline drops for nasal congestion 1, 2

For Persistent Cough (>4 weeks)

• A chest radiograph should be performed to aid in diagnosis 3
• Follow pediatric-specific cough management algorithms 3
• Consider common causes in this age group:
  • Protracted bacterial bronchitis
  • Tracheobronchomalacia
  • Foreign body aspiration
  • Post-infectious cough 4

Specific Treatments

For Suspected Protracted Bacterial Bronchitis (PBB)

• If wet cough persists >4 weeks with no other specific pointers:
  • Prescribe 2 weeks of antibiotics (amoxicillin as first choice)
  • Extend for another 2 weeks if cough persists 1

For Suspected Foreign Body

• Urgent referral for bronchoscopy if sudden onset of cough with choking episode 3, 4

For Suspected Pertussis

• Consider testing for Bordetella pertussis when clinically suspected (paroxysmal cough, post-tussive vomiting, or inspiratory whoop) 3

Important Cautions

• Do not use over-the-counter cough suppressants or cold medications in children under 2 years as they:

  • Offer no symptomatic relief
  • Place young children at risk for potential side effects and adverse reactions 2

• Avoid empirical treatment approaches for:

  • Gastroesophageal reflux disease (GERD)
  • Upper airway cough syndrome
  • Asthma

  Unless other features consistent with these conditions are present 3

Follow-up and Referral

• Schedule follow-up within 2-4 weeks if cough persists 1
• Consider referral to a pediatric pulmonologist if:
  • Cough persists despite appropriate management
  • Chest radiograph shows abnormalities
  • Specific cough pointers are present 3, 1

Common Pitfalls to Avoid

• Assuming adult causes of chronic cough apply to children 1
• Using cough suppressants which may be harmful by suppressing a protective reflex 4
• Prolonged empirical treatment without a specific diagnosis 3
• Failure to recognize that a persistent wet cough may indicate underlying respiratory disease requiring investigation 3, 4

By following these evidence-based guidelines, you can provide appropriate care for children under 2 years with chesty cough while minimizing unnecessary medication use and focusing on identifying and treating the underlying cause.