Treatment of Productive Cough in Children
For children with chronic wet or productive cough (>4 weeks duration) without specific disease pointers, antibiotics targeted at common respiratory bacteria for 2 weeks is the recommended first-line treatment. 1
Diagnostic Assessment
When evaluating a child with productive cough, consider:
- Duration of cough (acute <2 weeks, subacute 2-4 weeks, chronic >4 weeks)
- Presence of specific cough pointers that suggest underlying disease:
- Digital clubbing
- Coughing with feeding
- Failure to thrive
- Hemoptysis
- Recurrent pneumonia
- Abnormal lung examination
- Family history of chronic lung disease
Treatment Algorithm for Productive Cough in Children
Acute Productive Cough (<4 weeks)
- Supportive care is typically sufficient:
Chronic Productive/Wet Cough (>4 weeks)
First-line treatment: 2-week course of antibiotics targeting common respiratory bacteria (Streptococcus pneumoniae, Haemophilus influenzae, Moraxella catarrhalis) based on local antibiotic sensitivities 1
- Amoxicillin-clavulanate is commonly used 5
If cough resolves within 2 weeks: Diagnosis of protracted bacterial bronchitis (PBB) can be made 1
If cough persists after 2 weeks of antibiotics: Extend antibiotic treatment for an additional 2 weeks (total 4 weeks) 1
If cough persists after 4 weeks of appropriate antibiotics: Further investigations should be undertaken, including:
- Flexible bronchoscopy with quantitative cultures
- Chest CT scan
- Assessment for underlying conditions 1
Evidence Supporting Antibiotic Use
High-quality evidence supports the use of antibiotics for chronic wet cough in children. A Cochrane review found that antibiotics significantly reduced the proportion of children not cured at follow-up compared to placebo, with a number needed to treat of 3 5. This means for every 3 children treated with antibiotics, 1 additional child will have resolution of cough compared to placebo.
Special Considerations
Children with specific cough pointers: If specific cough pointers are present (digital clubbing, coughing with feeding), further investigations should be undertaken immediately to assess for underlying disease, rather than empiric antibiotic treatment 1
Monitoring: Re-evaluate children after 2 weeks of antibiotic treatment to assess response 1
Adverse effects: While antibiotics are effective, monitor for potential adverse effects such as diarrhea, rash, or allergic reactions 5
What to Avoid
Over-the-counter cough medications: These have minimal efficacy and potential for harm in children 2, 3, 4
Empiric treatment for GERD: Without specific GERD symptoms, empiric treatment is not recommended for cough in children 2
Prolonged antibiotic courses without investigation: If cough persists despite 4 weeks of appropriate antibiotics, further investigation is necessary rather than continuing antibiotics indefinitely 1
When to Refer
Refer to a specialist if:
- Cough persists despite 4 weeks of appropriate antibiotics
- Specific cough pointers emerge during treatment
- Recurrent episodes of productive cough occur despite appropriate treatment