Management of Pediatric Cough
The approach to pediatric cough must be based on cough characteristics (wet vs. dry) and duration (acute vs. chronic), with management targeted to the underlying etiology rather than empirical treatment of presumed adult conditions like GERD or upper airway cough syndrome. 1
Initial Assessment: Key Clinical Features
When evaluating a child with cough, immediately determine:
Cough duration: Acute (<4 weeks) vs. chronic (>4 weeks) 1
Presence of specific "cough pointers" that indicate serious underlying disease 1, 2:
Environmental factors: Tobacco smoke exposure must be identified 2
Parental concerns and expectations should be addressed 2
Management Algorithm for Acute Cough (<4 weeks)
For Children >1 Year Old:
- Honey is first-line treatment for symptomatic relief, offering more benefit than no treatment, diphenhydramine, or placebo 1, 2
- Do NOT prescribe over-the-counter cough and cold medicines—they have not been shown to reduce cough severity or duration 1, 2
- Avoid codeine-containing medications due to risk of serious side effects including respiratory distress 1, 2
When to Suspect Serious Pathology in Acute Cough:
- Consider foreign body aspiration if sudden onset cough, especially in toddlers 2
- Consider pertussis if paroxysmal cough with post-tussive vomiting 1
- Consider pneumonia if fever, tachypnea, respiratory distress, or oxygen saturation ≤92% 1
Management Algorithm for Chronic Cough (>4 weeks)
Step 1: Determine if Cough is Wet or Dry
For Chronic WET/Productive Cough (without specific cough pointers):
This is likely Protracted Bacterial Bronchitis (PBB):
Prescribe 2 weeks of antibiotics targeting common respiratory bacteria (Streptococcus pneumoniae, Haemophilus influenzae, Moraxella catarrhalis) 1, 2
If cough resolves within 2 weeks: Diagnose as clinically-defined PBB 1, 2
If wet cough persists after 2 weeks: Treat with an additional 2 weeks of appropriate antibiotics 1, 2
If cough persists after 4 weeks total of antibiotics: Perform further investigations including chest radiograph, spirometry, and consider referral for bronchoscopy, as there is increased risk of underlying lung disease such as bronchiectasis 1, 2
For Chronic DRY/Non-productive Cough:
Do NOT assume this is asthma—isolated chronic cough in children is rarely asthma, and "cough variant asthma" should not be routinely diagnosed. 1, 4
Evaluate for asthma risk factors 1, 2:
- Personal or family history of atopy
- Associated wheeze, exercise intolerance, or nocturnal symptoms
- Bronchodilator responsiveness
If asthma risk factors present: Consider a short trial (2-4 weeks) of inhaled corticosteroids (400 mcg/day beclomethasone equivalent) 1, 2
Consider post-infectious cough if following recent respiratory infection 2
Consider upper airway cough syndrome (post-nasal drip) if rhinorrhea or throat clearing 2
If non-specific dry cough without clear etiology: Observe for 2-4 weeks and re-evaluate for emergence of specific cough pointers 1, 2
Step 2: First-Line Investigations (When Indicated)
Obtain chest radiograph and spirometry when: 1, 2
- Specific cough pointers are present
- Cough does not resolve with appropriate initial management
- Structural abnormalities or airway reactivity need assessment
These tests have high positive likelihood ratios (can rule in disease when abnormal) but poor negative likelihood ratios (cannot rule out disease when normal). 1
Critical Pitfalls to Avoid
- Do NOT use empirical treatment approaches targeting GERD, upper airway cough syndrome, or asthma unless specific features of these conditions are present 1, 2
- Do NOT assume adult etiologies apply to children—common causes of chronic cough differ significantly between adults and children 1
- Do NOT ignore the "period effect"—cough may resolve naturally over time regardless of treatment, so response to therapy should be assessed within 2-3 weeks 1
- Do NOT routinely perform additional tests (skin prick testing, Mantoux, bronchoscopy, chest CT) unless specifically indicated by clinical findings 2
When to Refer or Escalate Care
Consider referral for: 2
- Failure to respond to appropriate initial management
- Concerning symptoms: hemoptysis, weight loss, persistent focal findings
- Recurrent episodes despite appropriate treatment
- Suspected anatomical abnormality requiring specialized evaluation
Special Considerations for Pneumonia
If pneumonia is suspected based on clinical features: 1
Indicators for hospital admission in infants:
- Oxygen saturation <92% or cyanosis
- Respiratory rate >70 breaths/min
- Difficulty breathing, grunting, or intermittent apnea
- Not feeding
- Family unable to provide appropriate supervision 1
Indicators for hospital admission in older children:
- Oxygen saturation <92% or cyanosis
- Respiratory rate >50 breaths/min
- Difficulty breathing or grunting
- Signs of dehydration
- Family unable to provide appropriate supervision 1
Antibiotic management for community-acquired pneumonia:
- Amoxicillin is first-choice for children <5 years 1
- Macrolide antibiotics (erythromycin, clarithromycin, azithromycin) may be used as first-line in children ≥5 years due to higher prevalence of Mycoplasma pneumoniae 1
- Oral antibiotics are safe and effective for children presenting with pneumonia 1
- Intravenous antibiotics reserved for severe cases or inability to absorb oral medications 1