Management of Dry Cough in Infants
For infants with dry cough, the primary approach is watchful waiting with reassessment, as most cases represent post-viral cough that resolves spontaneously within 2-4 weeks, and empirical treatment should be avoided unless specific disease features are present. 1
Initial Assessment Framework
When evaluating an infant with dry cough, immediately assess for specific cough pointers that indicate underlying disease requiring urgent investigation 1:
- Coughing with feeding (suggests aspiration or swallowing dysfunction) 1, 2
- Digital clubbing (indicates chronic lung disease) 1, 3
- Respiratory distress (tachypnea, retractions, grunting) 2, 3
- Growth failure or failure to thrive 2, 3
- Chest deformity 3
- Fever ≥39°C 2
The character of cough can suggest specific etiologies 1:
- Barking/brassy cough: croup, tracheomalacia, or habit cough 1
- Staccato cough: Chlamydia infection in infants 1
- Paroxysmal cough with/without whoop: pertussis 1, 3
Management Algorithm for Non-Specific Dry Cough
If NO Specific Cough Pointers Present:
Watchful waiting is the recommended approach 1:
- Most dry cough in infants represents post-viral cough or acute bronchitis that resolves spontaneously 1
- Reassess in 2-4 weeks 1
- Evaluate and eliminate environmental irritants, particularly tobacco smoke exposure 1, 3
- Address parental expectations and concerns 1
Critical Distinction from Adult Management:
Common adult causes of chronic cough (upper airway cough syndrome, GERD, asthma) should NOT be presumed to be common causes in children 1. The empirical approach of treating these conditions without specific features is explicitly not recommended 1.
When to Consider Specific Diagnoses
Asthma Consideration:
Only consider asthma if there are symptoms/signs of reversible airway obstruction 1:
- Polyphonic wheeze on examination 1
- Documented reversible airflow obstruction on spirometry (in children >3-6 years old) 1
- Do not use inhaled corticosteroids empirically for isolated dry cough without other asthma features 1
GERD Consideration:
Acid suppressive therapy should NOT be used solely for chronic cough 1. GERD treatment is only appropriate when 1:
- Recurrent regurgitation is present in infants 1
- Dystonic neck posturing (Sandifer syndrome) in infants 1
- Other GI symptoms consistent with pathological reflux are documented 1
Even when GI symptoms are present, treat according to GERD-specific guidelines for 4-8 weeks and reassess, not indefinitely for cough alone 1.
Investigations
For chronic dry cough (>4 weeks), obtain 1:
- Chest radiograph (specific but not sensitive—normal CXR doesn't exclude disease) 1
- Spirometry (if child >3-6 years and trained pediatric personnel available) 1
What NOT to Do
Never administer over-the-counter cough and cold medications to infants 4:
- These medications have caused infant deaths 4
- No FDA-approved dosing exists for children <2 years 4
- Effectiveness is not established in this age group 4
Avoid empirical treatment without specific disease features 1:
- Do not prescribe antibiotics for dry cough (antibiotics are only for chronic wet cough >4 weeks) 2, 3
- Do not prescribe asthma medications without evidence of reversible airway obstruction 1
- Do not prescribe GERD medications without GI symptoms 1
Red Flags Requiring Immediate Evaluation
Refer urgently or investigate further if 2, 3:
- Any specific cough pointers develop (feeding difficulties, clubbing, respiratory distress) 2, 3
- High fever ≥39°C 2
- Inability to feed or signs of dehydration 2
- Cough persists beyond 4 weeks 1
- Development of wet/productive cough 2, 3
Special Considerations in Infants
Tracheomalacia and structural airway abnormalities are more common causes of chronic cough in infants than in older children 5. Consider these diagnoses when 5:
- Cough began in the newborn period 5
- Homophonous wheeze or "tracheal cough" is present 5
- Symptoms suggest central airway obstruction 5
Period Effect and Natural History
An important caveat: cough has a substantial placebo effect (up to 80%) and period effect (spontaneous improvement with time) 1. This means that improvement after any intervention within 2-3 weeks may simply reflect natural resolution rather than treatment efficacy 1. This underscores why watchful waiting is appropriate for non-specific dry cough 1.