What is the recommended treatment for cough in children?

Treatment of Cough in Children

Treatment of cough in children must be etiology-based rather than empirical, with chronic wet cough treated with antibiotics targeting respiratory bacteria, while over-the-counter cough medications and codeine should be avoided entirely. 1

Acute Cough Management

First-Line Treatment

• Honey is the recommended first-line therapy for children over 1 year of age with acute cough, showing superior efficacy compared to no treatment, placebo, or diphenhydramine 2
• Honey should never be given to infants under 12 months due to risk of infant botulism 2
• Over-the-counter cough and cold medicines have little to no benefit and carry risk of adverse events—they should not be prescribed 2, 3
• Codeine-containing medications must be avoided due to potential serious side effects including respiratory depression and opioid toxicity 2, 4

Chronic Cough Management (>4 weeks duration)

Initial Approach

• Management must be based on the etiology of the cough, not empirical treatment of presumed asthma, GERD, or upper airway cough syndrome unless specific features of these conditions are present 1
• Minimum initial investigations should include chest radiograph and spirometry (if age-appropriate) 1, 3
• Determine and address exacerbating factors, particularly environmental tobacco smoke exposure 1

Chronic Wet/Productive Cough Without Specific Pointers

This represents protracted bacterial bronchitis (PBB), the most common etiology requiring specific treatment:

• Treat with 2 weeks of antibiotics targeting common respiratory bacteria (Streptococcus pneumoniae, Haemophilus influenzae, Moraxella catarrhalis) according to local antibiotic sensitivities 1
• If cough resolves within 2 weeks of antibiotic treatment, diagnose as PBB 1
• If wet cough persists after 2 weeks of appropriate antibiotics, extend treatment for an additional 2 weeks 1
• If wet cough persists after 4 weeks total of appropriate antibiotics, undertake further investigations including flexible bronchoscopy with quantitative cultures and/or chest CT 1

Chronic Wet Cough WITH Specific Pointers

Specific pointers include coughing with feeding, digital clubbing, hemoptysis, or failure to thrive:

• Further investigations must be undertaken immediately (flexible bronchoscopy and/or chest CT, assessment for aspiration, evaluation of immunologic competency) to assess for underlying disease such as cystic fibrosis, bronchiectasis, or immune deficiency 1

Non-Specific Dry Cough

• If cough does not resolve within 2-4 weeks, re-evaluate for emergence of specific etiological pointers 1, 2
• For children with non-specific cough AND risk factors for asthma (family history, atopy, wheeze), a short 2-4 week trial of inhaled corticosteroids (400 mcg/day beclomethasone or budesonide equivalent) may be warranted 1
• These children must always be re-evaluated in 2-4 weeks 1
• If cough does not resolve during the medication trial within the expected response time, the medication should be withdrawn 1

GERD-Related Cough

Key Principle

GERD is NOT a common cause of isolated chronic cough in children without gastrointestinal symptoms 1

Treatment Recommendations

• Do not use GERD treatments when there are no GI clinical features (no recurrent regurgitation, dystonic neck posturing in infants, or heartburn/epigastric pain in older children) 1
• For children with symptoms and signs consistent with pathological reflux, treat GERD according to evidence-based GERD-specific guidelines for 4-8 weeks and re-evaluate 1
• Acid suppressive therapy should not be used solely for chronic cough 1

Critical Pitfalls to Avoid

What NOT to Do

• Never use empirical treatment approaches (treating presumed asthma/GERD/upper airway cough syndrome) without specific features consistent with these conditions 1
• Do not routinely perform additional tests (skin prick test, Mantoux, bronchoscopy, chest CT) unless individualized based on clinical symptoms and signs 1
• Do not use over-the-counter cough medications—they lack efficacy and carry risks 2, 5
• Never prescribe codeine or derivatives to children under 12 years, and avoid in children 12-18 years with respiratory conditions 4

When to Seek Specialist Evaluation

• Cough persisting beyond 2-4 weeks without response to appropriate initial management 2, 3
• Presence of concerning symptoms: hemoptysis, weight loss, persistent focal findings, difficulty breathing, or changes in mental status 2, 3
• Chronic productive purulent cough requiring investigation for bronchiectasis and underlying causes 1

Parental Expectations

• Determine parental and child's expectations, seek and address their specific concerns 1
• Explain that most acute coughs are self-limited and part of expected childhood respiratory infections 1
• Emphasize that symptomatic cough suppression is rarely appropriate and that identifying the underlying cause is essential 1