What is the best course of treatment for a cough in a 5-month-old infant?

Management of Cough in a 5-Month-Old Infant

For a 5-month-old infant with cough, provide supportive care only—do not use any over-the-counter cough or cold medications, as they are contraindicated due to serious safety concerns and lack of efficacy in this age group. 1

Immediate Safety Assessment

First, determine if the infant requires urgent medical evaluation by assessing for these red flags:

• Respiratory distress indicators: respiratory rate >70 breaths/min, difficulty breathing, grunting, intermittent apnea, or cyanosis 2, 1
• Oxygen saturation <92% (if measurable) 2, 1
• Feeding difficulties: not feeding or signs of dehydration 2, 1
• Specific cough pointers: coughing with feeding (suggests aspiration), digital clubbing, or failure to thrive 2, 3

If any of these are present, the infant requires immediate hospital evaluation. 2, 1

Medication Contraindications

Critical safety point: The American Academy of Pediatrics explicitly recommends against OTC cough and cold medications in children under 2 years due to documented fatalities—43 deaths from decongestants and 41 deaths from antihistamines occurred in infants under this age between 1969-2006. 1 These medications lack proven efficacy and carry serious toxicity risks. 1

Supportive Care Measures

For an infant without red flags, provide the following evidence-based supportive care:

• Fever management: Use antipyretics (acetaminophen or ibuprofen if >6 months) to keep the infant comfortable 2, 1
• Hydration: Ensure adequate fluid intake to help thin secretions 1
• Nasal congestion relief: Gentle suctioning of nostrils may help improve breathing 1
• Positioning: A supported sitting position may help expand lungs and improve respiratory symptoms 1
• Environmental control: Eliminate tobacco smoke exposure, which exacerbates respiratory symptoms 2, 1

Antibiotic Decision-Making

Do not use antibiotics empirically for acute cough in this age group. 2, 3 Young infants with mild lower respiratory symptoms do not need antibiotics. 2, 1

Consider antibiotics only if:

• Confirmed bacterial pneumonia: High fever, respiratory distress, or radiographic consolidation—use amoxicillin 80-100 mg/kg/day divided three times daily 3
• Severe presentation: Toxic appearance, high fever ≥39°C, or signs suggesting serious bacterial infection 3
• Concurrent acute otitis media: In infants under 2 years with confirmed AOM 3

Follow-Up Timeline

• Review at 48 hours if symptoms are not improving or are worsening 2, 1
• At 4 weeks: If cough persists to this point, it transitions from acute to chronic cough and requires systematic evaluation with chest radiograph and consideration of conditions like protracted bacterial bronchitis 2, 3

Important Caveats

Avoid chest physiotherapy—it is not beneficial and should not be performed in children with respiratory infections. 2, 1

Nasogastric tubes should be avoided in severely ill infants as they may compromise breathing through small nasal passages. 2, 1

Do not diagnose asthma based on isolated cough in this age group—asthma is rarely the cause of isolated chronic cough in infants, and the term "cough variant asthma" should not be used without objective evidence of airway obstruction. 4, 5

Parental Education

Provide families with clear information about:

• Managing fever appropriately 2, 1
• Preventing dehydration 2, 1
• Recognizing signs of deterioration that require immediate medical attention 2, 1
• Expected natural course—most acute coughs from viral infections resolve spontaneously 6, 5