What are the treatment options for viral cough in children?

Treatment of Viral Cough in Children

Do not use over-the-counter cough and cold medicines in children with viral cough, as they provide no benefit and can cause significant morbidity and mortality, especially in young children. 1

Primary Treatment Approach

For Acute Viral Cough (Most Common Scenario)

Honey is the only recommended treatment for symptomatic relief in children over 1 year of age. 1, 2

• Honey provides more relief than no treatment, diphenhydramine, or placebo 1, 2
• Honey is equivalent to dextromethorphan in efficacy but safer 1, 2
• Never give honey to infants under 12 months due to risk of infant botulism 2

Watchful Waiting is Standard Care

Most viral coughs are self-limiting and resolve spontaneously without medication. 1, 3

• Provide supportive care and parental education about the natural course of illness 1, 3
• Address parental expectations and specific concerns 1
• Most acute viral coughs resolve within 2-4 weeks 1, 3

Medications to AVOID

Over-the-Counter Cough Medicines: Do Not Use

Cough suppressants and OTC cough/cold medicines should not be used in children as they may cause significant morbidity and mortality. 1

• No evidence these medications make cough less severe or resolve sooner 1
• Associated with adverse events including reported deaths from toxicity in young children 1
• This includes preparations containing antihistamines and dextromethorphan 1

Codeine: Absolutely Contraindicated

Avoid codeine-containing medications due to potential serious side effects including respiratory distress. 1, 2

Antihistamines: Ineffective in Children

Antihistamines have minimal to no efficacy for relieving cough in children, unlike in adults. 1, 3

When to Re-evaluate

Follow-up Timeline

If cough persists beyond 2-4 weeks, re-evaluate the child for emergence of specific etiological pointers. 1, 3

• Most children with nonspecific viral cough will spontaneously resolve 1
• Persistent cough may indicate an underlying condition requiring specific treatment 1, 3

Red Flags Requiring Immediate Evaluation

Look for "cough pointers" suggesting non-viral etiology: 3

• Wheezing (suggests asthma) 3
• Digital clubbing 3
• Coughing with feeding 3
• Abnormal chest radiograph or spirometry 3
• Difficulty breathing or increased work of breathing 2
• Fever that persists or appears later in illness 2

Environmental Modifications

Identify and eliminate exacerbating factors, particularly tobacco smoke exposure. 1, 3

• Address air pollutants and allergens 3
• Initiate interventions for cessation of environmental exposures 1

Special Consideration: Trial of Inhaled Corticosteroids

Only for children with nonspecific cough AND risk factors for asthma: 1, 3

• Consider a short 2-4 week trial of beclomethasone 400 μg/day or equivalent budesonide dose 1, 3
• However, most children with nonspecific cough do NOT have asthma 1
• Always re-evaluate in 2-4 weeks 1
• If no response within expected timeframe, withdraw medication and consider other diagnoses 1

Key Clinical Pitfalls to Avoid

• Do not prescribe OTC cough medicines - they are ineffective and potentially harmful 1
• Do not use adult treatment approaches in children - etiologies and treatments differ 1, 3
• Do not continue ineffective medications - if no response within expected timeframe, stop and reassess 1, 3
• Do not forget to address parental concerns - education about natural course is essential 1, 3