What are the recommended treatments for cough in pediatric patients?

Recommended Treatments for Cough in Pediatric Patients

For children with acute cough, over-the-counter cough and cold medicines should not be prescribed as they have not been shown to effectively reduce cough severity or duration and may cause significant morbidity and mortality, especially in young children. 1, 2

First-Line Treatment Options

Honey

• Honey may offer more relief for cough symptoms than no treatment, diphenhydramine, or placebo 1, 2
• Recommended administration: 10ml of honey mixed with milk or warm water given before bedtime, may be given up to three times daily 2, 3
• Important safety note: Honey should only be used in children over 12 months of age due to risk of infant botulism 4

Supportive Care

• Address underlying causes rather than suppressing the cough symptom 2
• Ensure adequate hydration
• Humidification of air may help relieve symptoms

Management Algorithm Based on Cough Type

1. Non-Specific Acute Cough

• First-line: Honey (if >12 months old) 2, 5
• Avoid over-the-counter cough suppressants including dextromethorphan 1, 2
• Re-evaluate if cough does not resolve within 2-4 weeks for emergence of specific etiological pointers 1

2. Cough with Asthma Risk Factors

• Consider a short trial (2-4 weeks) of inhaled corticosteroids (beclomethasone 400 μg/day or equivalent) 1, 2
• Re-evaluate in 2-4 weeks 1
• Consider short-acting beta-agonist (SABA) such as salbutamol as needed for symptom relief 2
• Discontinue if no improvement after trial period 2

3. Wet/Productive Cough Suggestive of Bacterial Infection (Protracted Bacterial Bronchitis)

• Appropriate antibiotics for 2 weeks targeting common respiratory bacteria 2
• If cough persists, extend antibiotic treatment for additional 2 weeks 2
• Further investigations if cough persists after 4 weeks of antibiotics 2

4. Cough with GERD Symptoms

• Only treat for GERD if GI symptoms are present 2
• Avoid empiric GERD treatments when there are no GI clinical features 2

Special Considerations

Codeine-Containing Medications

• Avoid using codeine-containing medications because of potential for serious side effects including respiratory distress 1

When to Re-evaluate

• If cough does not resolve within 2-4 weeks 1, 2
• If specific etiological pointers emerge during treatment 2
• If medication trial does not produce improvement within expected response time 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 2

Diagnostic Approach

• Chest radiograph as minimum investigation for persistent cough 2
• Spirometry if age-appropriate 2
• Consider pertussis testing if clinically suspected 2

Common Pitfalls to Avoid

1. Using over-the-counter cough medications in young children due to risk of significant adverse effects 1, 2
2. Prescribing codeine-containing medications due to risk of respiratory depression 1
3. Assuming all chronic cough is asthma (most children with non-specific cough do not have asthma) 1, 2
4. Empirically treating for GERD without specific GI symptoms 2
5. Failing to re-evaluate children whose cough does not improve with initial treatment 1, 2

Honey has been shown in multiple studies to be effective for symptomatic relief of cough in children, with evidence suggesting it may be superior to placebo and some conventional medications 3, 6, 5. The evidence for honey is moderate-certainty, with studies showing it probably reduces cough frequency better than no treatment or placebo 5.