What is the treatment for dry cough in children?

Treatment of Dry Cough in Children

The treatment of dry cough in children should be based on identifying and addressing the underlying cause rather than using over-the-counter cough medications, which have minimal efficacy and potential for harm, especially in children under 4 years of age. 1

Initial Approach

Assessment

• Determine if the cough is wet/productive or dry
• Look for specific cough pointers (indicators of underlying disease)
• Categorize duration: acute (<2 weeks), subacute (2-4 weeks), or chronic (>4 weeks) 1

Red Flags Requiring Prompt Medical Attention

• Digital clubbing
• Chest pain
• Failure to thrive
• Feeding difficulties
• Abnormal lung examination
• Hemoptysis
• Recurrent pneumonia
• Family history of chronic lung disease
• Immunodeficiency 1

Management Algorithm for Dry Cough

Step 1: Initial Management (0-2 weeks)

• Watch, wait, and review as most cases are post-viral cough or acute bronchitis 1
• Avoid over-the-counter cough medications, especially in children under 4 years 1
• For symptomatic relief in children >1 year: Honey (10ml mixed with milk or warm water) before bedtime, up to three times daily 1

Step 2: Persistent Cough (2-4 weeks)

• Re-evaluate for emergence of specific etiological pointers 2
• If risk factors for asthma are present, consider a short trial (2-4 weeks) of inhaled corticosteroids (ICS) at 400 μg/day of beclomethasone equivalent 2, 1
• Set a defined limited duration for ICS trial and discontinue if no improvement 1

Step 3: Chronic Cough (>4 weeks)

• If cough persists despite appropriate management, or if specific cough pointers emerge, refer to a specialist 1
• Consider referral to a pediatric pulmonologist if cough is unresponsive to treatment 1

Special Considerations

Asthma-Related Cough

• For children with suspected asthma or cough variant asthma with risk factors:
  • Short trial (2-4 weeks) of inhaled corticosteroids (400 μg/day of beclomethasone equivalent)
  • Short-acting beta-agonist (SABA) such as salbutamol as needed for symptom relief
  • Re-evaluate in 2-4 weeks 2, 1
• Cough unresponsive to ICS should not be treated with increased doses of ICS 2

Foreign Body Aspiration

• Always consider this possibility in children with chronic cough
• A history of choking episode should be sought, but aspiration may be unwitnessed
• A normal chest X-ray does not exclude foreign body inhalation 2

Otogenic Causes

• Examine ears for foreign material or structures that may trigger Arnold's ear-cough reflex
• This is a rare cause of childhood chronic cough 2

What to Avoid

• Dextromethorphan and other over-the-counter cough medications have minimal efficacy and potential for harm in children 2, 1
• Antihistamines have minimal to no efficacy in relieving cough in children 2
• Empiric treatment for GERD without specific symptoms is not recommended, as a Cochrane review found no beneficial effect of GERD therapies for cough in children 2
• Misdiagnosing asthma and empiric ICS treatment without asthma features 1

Follow-up and Monitoring

• Re-evaluate in 2-4 weeks to assess response to treatment 2, 1
• If cough resolves with ICS use, be aware that the child does not necessarily have asthma and should be re-evaluated off asthma treatment 2
• Monitor for potential adverse effects of ICS in young children, including impact on HPA axis, growth effects, and risk of oral candidiasis 1

By following this structured approach to managing dry cough in children, clinicians can provide appropriate care while avoiding unnecessary medications that may cause harm without providing benefit.