What is the recommended treatment for a persistent cough in a child under 1 year old that is affecting their sleep?

Management of Persistent Cough Affecting Sleep in Infants Under 1 Year

For infants under 1 year with persistent cough affecting sleep, the recommended approach is to identify the cough characteristics (wet vs. dry) and treat accordingly, with antibiotics targeted at common respiratory bacteria being the first-line treatment for wet cough.

Initial Assessment

• Determine if the cough is wet/productive or dry, as this guides the management pathway 1
• Check for specific cough pointers that may indicate underlying disease (e.g., coughing with feeding, digital clubbing, chest wall deformity) 1
• Evaluate for environmental triggers, particularly tobacco smoke exposure 1
• Assess parental expectations and concerns about the cough 1

Management Based on Cough Characteristics

For Wet/Productive Cough:

• For infants with wet/productive cough without specific cough pointers, provide 2 weeks of antibiotics targeted at common respiratory bacteria (Streptococcus pneumoniae, Haemophilus influenzae, Moraxella catarrhalis) based on local antibiotic sensitivities 1
• If cough resolves within 2 weeks of antibiotic treatment, a diagnosis of protracted bacterial bronchitis (PBB) can be made 1
• If cough persists after initial 2-week antibiotic course, provide an additional 2 weeks of appropriate antibiotics 1
• If cough persists after 4 weeks of appropriate antibiotics, further investigations (e.g., flexible bronchoscopy, chest CT) should be considered 1

For Dry/Non-specific Cough:

• Watch, wait, and review approach is appropriate for most cases, as these are usually post-viral coughs 1
• Re-evaluate in 2-4 weeks to check for emergence of specific etiological pointers 1
• If risk factors for asthma are present, a short 2-4 week trial of inhaled corticosteroids (400 μg/day of beclomethasone equivalent) may be considered, with re-evaluation after this period 1

Important Considerations

• Avoid over-diagnosis of asthma in infants with persistent cough, as this is common and can lead to unnecessary medication use with potential side effects 2
• Do not use treatments for gastroesophageal reflux disease (GERD) when there are no GI clinical features of reflux 1
• Consider foreign body inhalation in cases of sudden-onset persistent cough, even if the choking episode was not witnessed 1
• Examine the ears to rule out otogenic causes (Arnold's ear-cough reflex), although this is a rare cause of chronic cough in children 1

Cautions and Pitfalls

• Avoid using over-the-counter cough medications in infants under 1 year, as there is limited evidence for efficacy and potential for adverse effects 3
• Be aware that post-infectious cough can persist for several weeks after a viral infection and may resolve spontaneously 4
• Recognize that persistent cough in infants may indicate serious underlying conditions requiring investigation, particularly if specific cough pointers are present 1, 5
• Avoid prolonged empiric medication trials without clear evidence of benefit 2

By following this structured approach based on cough characteristics, most cases of persistent cough affecting sleep in infants under 1 year can be effectively managed, improving both the infant's and family's quality of life.