What is the appropriate use of inhaled corticosteroids (ICS), such as fluticasone (fluticasone) or budesonide (budesonide), in a child less than or equal to 2 years with chronic cough?

Inhaled Corticosteroids for Chronic Cough in Children ≤2 Years

Inhaled corticosteroids (ICS) should not be routinely used for chronic cough in children ≤2 years unless specific features of asthma are present. 1

Assessment of Chronic Cough in Young Children

Chronic cough in children is defined as daily cough lasting at least 4 weeks 1, 2. When evaluating a child ≤2 years with chronic cough, the following approach is recommended:

1. Characterize the cough:

   • Determine if the cough is wet/productive or dry 1, 2
   • Look for specific cough pointers (indicators of underlying disease) 1

2. Initial investigations:

   • Chest radiograph should be performed 1
   • Spirometry is not applicable in this age group (usually only reliable in children >3-6 years) 1

Management Algorithm

For Non-specific Dry Cough (no specific cough pointers):

1. Initial approach: Watch, wait, and review

   • This is often post-viral cough or acute bronchitis 1
   • Review in 1-2 weeks to assess if cough is resolving

2. If cough persists:

   • Evaluate for risk factors for asthma
   • If asthma risk factors present: A short (2-4 weeks) trial of ICS may be considered at 400 μg/day of budesonide equivalent 1
   • Re-evaluate in 2-4 weeks 1, 2
   • If cough resolves with ICS, discontinue treatment and reassess (resolution may be due to spontaneous improvement rather than medication effect) 1

For Wet/Productive Cough:

1. Consider protracted bacterial bronchitis (PBB):
   • Treat with antibiotics for 2 weeks targeting common respiratory bacteria 1, 2, 3
   • If cough persists, repeat antibiotic course for another 2 weeks 1

Evidence on ICS Use in Young Children

The evidence for using ICS in children ≤2 years with chronic cough is limited:

• A Cochrane review found no significant difference between beclomethasone (400 μg/day) and placebo in reducing cough frequency 4
• Very high-dose ICS might show small improvements, but the clinical impact is unlikely to be beneficial 4
• The FDA label for budesonide inhalation suspension notes that it's indicated for maintenance treatment of asthma in children 12 months to 8 years of age, but not for relief of acute bronchospasm 5

Important Considerations and Cautions

1. Potential adverse effects of ICS in young children:

   • Impact on HPA axis, especially in susceptible individuals 5
   • Potential growth effects with long-term use 5
   • Risk of oral candidiasis (thrush) 5

2. Monitoring if ICS is prescribed:

   • Set a defined limited duration (2-4 weeks) 1
   • Discontinue if no improvement 1
   • If improvement occurs, attempt to wean off ICS to determine if ongoing treatment is necessary 1

3. When to refer:

   • If cough persists despite appropriate management
   • If specific cough pointers emerge
   • If wet cough persists after 4 weeks of antibiotics 2, 3

Key Pitfalls to Avoid

1. Misdiagnosing asthma: Not all chronic cough in young children is asthma; avoid empiric ICS treatment without asthma features 1

2. Prolonged unnecessary treatment: If using ICS, always reassess after 2-4 weeks and discontinue if ineffective 1, 2

3. Missing serious underlying conditions: Always evaluate for specific cough pointers that may indicate need for further investigation 1

4. Ignoring wet cough: Persistent wet cough may indicate protracted bacterial bronchitis requiring antibiotics, not ICS 1, 3

In summary, ICS should be reserved for children ≤2 years with chronic cough who have specific features suggesting asthma, used for a limited trial period (2-4 weeks), and discontinued if ineffective. The management should be guided by cough characteristics and associated clinical features rather than empiric treatment.