What is the recommended treatment for a pediatric cough?

Cough Medicine for Children

For children over 1 year old with acute cough, give honey as the first-line treatment—it provides better symptom relief than over-the-counter cough medicines, which should not be used. 1, 2

Recommended Treatment Approach

For Acute Cough (< 4 weeks)

Honey is the evidence-based first choice:

• Give honey (approximately 2.5-10 mL) before bedtime for children over 12 months of age 1, 2
• Honey reduces cough frequency, severity, and improves sleep for both children and parents better than no treatment or placebo 1, 3
• Honey performs similarly to dextromethorphan but is safer and more accessible 2, 3
• Never give honey to infants under 12 months due to botulism risk 2

What NOT to use:

• Over-the-counter cough and cold medicines should not be prescribed—they have not been shown to reduce cough severity or duration and carry risk of adverse events including significant morbidity and mortality, especially in young children 4, 1
• Codeine-containing medications must be avoided due to potential serious side effects including respiratory distress 1, 2
• Antihistamine-decongestant combinations are ineffective in children under 15 years 4

For Chronic Wet/Productive Cough (> 4 weeks)

This suggests protracted bacterial bronchitis:

• Prescribe a 2-week course of antibiotics targeting common respiratory bacteria (such as amoxicillin-clavulanate) 1
• If cough persists after 2 weeks, give an additional 2-week course of antibiotics 1
• When cough resolves with antibiotics, this confirms the diagnosis of protracted bacterial bronchitis 1

For Chronic Dry Cough (> 4 weeks)

Evaluate for asthma if risk factors present:

• Consider a short trial (2-4 weeks) of inhaled corticosteroids (beclomethasone 400 mcg/day or equivalent budesonide) only in children with asthma risk factors such as wheeze, exercise intolerance, or nocturnal symptoms 4, 1
• Most children with nonspecific cough do NOT have asthma 4
• Always re-evaluate in 2-4 weeks; if no improvement, stop the medication and consider other diagnoses 4, 1

Critical Management Principles

Avoid empirical treatment without specific findings:

• Treatment should be etiologically based whenever possible 4, 1
• If empirical therapy is used, limit it to a defined duration to confirm or refute the diagnosis 1
• Withdraw medications if cough doesn't resolve within the expected response time 4

Address environmental factors:

• Identify and advise cessation of environmental tobacco smoke exposure and other pollutants 4, 1
• Address parental expectations and specific concerns 4, 1

When to Re-evaluate or Refer

Re-evaluate if:

• Cough persists beyond 2-4 weeks to assess for emergence of specific etiologic pointers 4, 2
• Child develops difficulty breathing, persistent fever, changes in mental status, or refusal to eat/drink 2

Consider referral for:

• Failure to respond to appropriate initial management 1
• Concerning symptoms such as hemoptysis, weight loss, or persistent focal findings 1
• Recurrent episodes despite appropriate treatment 1

Common Pitfalls to Avoid

• Do not use cough suppressants in children—they provide no benefit and may cause harm 4
• Do not routinely perform additional tests (skin prick, bronchoscopy, CT) unless specifically indicated by clinical findings 1
• Do not continue ineffective medications beyond the trial period 4
• Remember that nonspecific cough may spontaneously resolve, but requires monitoring for development of specific diagnostic features 4