What is the best approach to treat a persistent dry cough in an infant less than 1 year?

Management of Persistent Dry Cough in Infants Less Than 1 Year Old

For infants less than 1 year old with persistent dry cough, the recommended approach is a "watch, wait, and review" strategy as most cases represent post-viral cough or acute bronchitis that will resolve without specific treatment. 1

Initial Assessment

• Evaluate for specific "cough pointers" that may indicate underlying disease requiring further investigation 1:

  • Digital clubbing
  • Failure to thrive
  • Coughing with feeding
  • Abnormal chest examination findings
  • Hypoxia/cyanosis
  • Chest pain
  • Hemoptysis
  • Abnormal cough characteristics (brassy, paroxysmal with/without post-tussive vomiting, staccato)

• Consider common causes of persistent dry cough in infants 1, 2:

  • Post-viral cough (most common)
  • Foreign body inhalation
  • Upper airway disorders
  • Medication side effects
  • Pertussis or mycoplasma infection
  • Gastroesophageal reflux disease (GERD)
  • Ear problems

• Assess environmental factors that may exacerbate cough 1:

  • Tobacco smoke exposure
  • Other indoor/outdoor pollutants

Management Approach

For Non-Specific Dry Cough (No Cough Pointers)

1. Watch, wait, and review approach 1

   • Reassure parents that most post-viral coughs will resolve spontaneously
   • Schedule follow-up in 2-4 weeks 1
   • Avoid unnecessary medications

2. Avoid empiric treatments unless specific indications exist 1

   • Do not use inhaled corticosteroids unless there are other features of asthma 1
   • Do not use acid suppression therapy for GERD unless there are gastrointestinal symptoms 1
   • Avoid over-the-counter cough suppressants and antihistamines in infants due to lack of efficacy and potential harm 3

3. Environmental modifications 1

   • Eliminate tobacco smoke exposure
   • Optimize indoor air quality
   • Maintain adequate hydration

When to Consider Further Evaluation

• If dry cough persists beyond 4 weeks despite conservative management 1
• If specific cough pointers develop during observation 1
• If cough changes character (e.g., becomes wet/productive) 1

Special Considerations

• If cough becomes wet/productive: Consider a 2-week course of antibiotics targeting common respiratory bacteria (Streptococcus pneumoniae, Haemophilus influenzae, Moraxella catarrhalis) as this may indicate protracted bacterial bronchitis 1

• If asthma-like features develop: Consider a trial of bronchodilators, but note that diagnosing asthma in infants less than 1 year is challenging 1

• If feeding-related cough: Consider evaluation for aspiration with video-fluoroscopic swallowing studies 1

Diagnostic Testing

• Chest radiograph should be performed if cough persists beyond 4 weeks or if specific cough pointers are present 1

• Additional tests should not be routinely performed but individualized based on clinical findings 1:

  • Swallowing studies if aspiration is suspected
  • Flexible bronchoscopy if foreign body or airway abnormality is suspected
  • Testing for pertussis if clinically indicated

Important Caveats

• Avoid the adult approach of empirically treating for upper airway cough syndrome, GERD, or asthma unless specific features of these conditions are present 1

• Recognize that chronic cough in infants may signify serious underlying disease if accompanied by specific cough pointers, requiring prompt specialist referral 1, 4

• Persistent dry cough in infants rarely requires pharmacologic intervention and most cases will resolve with time 2, 5