What are the recommended treatments for a cough in children?

Recommended Treatments for Cough in Children

For children with acute cough, honey is recommended as the first-line treatment as it offers more relief for cough symptoms than no treatment, diphenhydramine, or placebo. 1

Treatment Based on Cough Type and Duration

Acute Cough (< 4 weeks)

• Honey should be used for symptom relief in children old enough to safely consume it (typically >1 year) 1, 2
• Over-the-counter cough and cold medicines should NOT be prescribed as they have not been shown to make cough less severe or resolve sooner 1, 3
• Codeine-containing medications should be avoided due to potential serious side effects including respiratory distress 1
• Most acute coughs are viral and self-limiting, requiring only supportive care 3, 4

Non-Specific Chronic Cough (> 4 weeks)

• If cough does not resolve within 2-4 weeks, the child should be re-evaluated for emergence of specific etiological pointers 1
• When risk factors for asthma are present, a short (2-4 weeks) trial of 400 mg/day of beclomethasone equivalent may be warranted, with re-evaluation in 2-4 weeks 1
• Empirical treatment approaches not based on specific findings should be avoided 1, 2

Chronic Wet/Productive Cough (> 4 weeks)

• For children with chronic wet cough without specific pointers, a 2-week course of antibiotics targeted to common respiratory bacteria (Streptococcus pneumoniae, Haemophilus influenzae, Moraxella catarrhalis) is recommended 1
• If cough persists after 2 weeks of appropriate antibiotics, an additional 2 weeks of antibiotics is recommended 1
• If cough persists after 4 weeks of appropriate antibiotics, further investigations (e.g., flexible bronchoscopy, chest CT) should be undertaken 1
• When chronic wet cough resolves with antibiotics, a diagnosis of protracted bacterial bronchitis (PBB) can be made 1

Special Considerations

When to Investigate Further

• Children with chronic wet cough and specific cough pointers (e.g., coughing with feeding, digital clubbing) require further investigations to assess for underlying disease 1
• Chest radiograph and spirometry are recommended as first-line investigations when structural abnormalities are suspected 1, 2
• Additional tests (skin prick test, Mantoux, bronchoscopy, chest CT) should not be routinely performed but individualized based on clinical findings 1

Addressing Environmental Factors

• Environmental tobacco smoke exposure and other environmental pollutants should be identified and cessation advised 1, 2
• Parents' expectations and concerns should be determined and addressed 1

Common Pitfalls to Avoid

• Avoid using codeine-containing medications due to risk of respiratory depression 1, 3
• Do not use over-the-counter cough and cold medicines as they lack efficacy and may cause adverse effects 1, 3
• Avoid empirical treatment for GERD, upper airway cough syndrome, or asthma unless other features consistent with these conditions are present 1, 2
• Do not over-diagnose asthma in children with chronic non-specific cough 5, 6
• Avoid delaying diagnosis of serious underlying conditions by prolonged empiric treatment without appropriate evaluation 3, 7

Algorithm for Cough Management in Children

1. Determine if cough is acute (<4 weeks) or chronic (>4 weeks) 1
2. Classify cough as wet/productive or dry/non-productive 1, 2
3. Look for specific cough pointers (e.g., digital clubbing, coughing with feeding) 1
4. For acute cough: use honey (if >1 year old), avoid OTC medications 1
5. For chronic wet cough without specific pointers: treat with antibiotics for 2 weeks 1
6. For chronic dry cough with asthma risk factors: consider short trial of inhaled corticosteroids 1
7. If treatment fails or specific pointers present: pursue appropriate investigations 1