What is the management for a toddler presenting with cough and rhinitis?

Management of Cough and Rhinitis in Toddlers

For a toddler with cough and rhinitis, avoid all over-the-counter cough and cold medications, as they lack proven efficacy and carry serious safety risks including death in this age group. 1, 2

What NOT to Do

• Do not use OTC cough and cold medications (antihistamines, decongestants, cough suppressants) in children under 2 years of age 1, 2
• Between 1969-2006, there were 54 deaths from decongestants and 69 deaths from antihistamines in children under 6 years, with the majority occurring in infants under 2 years 1, 2
• Major pharmaceutical companies voluntarily removed these products from the market for children under 2 years in 2007 1, 2
• Do not use topical nasal decongestants in children under 1 year due to narrow therapeutic window and risk of cardiovascular/CNS toxicity 2
• Do not use codeine-containing medications due to risk of respiratory distress 3
• Dextromethorphan products are labeled to not be used in children with chronic cough that occurs with too much phlegm 4

Recommended Supportive Care Approach

The cornerstone of management is supportive care with close monitoring:

Immediate Symptomatic Relief

• Ensure adequate hydration to help thin secretions 2
• Use antipyretics (acetaminophen or ibuprofen) to keep the child comfortable and help with coughing 2
• Gentle nasal suctioning may help improve breathing in children with nasal congestion 2
• Supported sitting position may help expand lungs and improve respiratory symptoms 2

Hygiene Measures

• Handwashing with soap and proper hand hygiene can help prevent transmission of respiratory viruses 2
• Address environmental tobacco smoke exposure if present 3

When to Escalate Care

Seek immediate medical attention if the toddler exhibits:

• Respiratory rate >70 breaths/min (infants) or >50 breaths/min (older children) 2
• Difficulty breathing, grunting, or cyanosis 2
• Oxygen saturation <92% if measured 2
• Not feeding well or signs of dehydration 2
• Persistent high fever or worsening symptoms 2

Follow-Up Timeline

• Review by healthcare provider if symptoms are deteriorating or not improving after 48 hours 2
• If cough persists beyond 3-4 weeks, this transitions to "prolonged acute cough" and warrants further evaluation 2
• At 4 weeks duration, the cough becomes "chronic" and requires systematic evaluation including chest radiograph and spirometry (if age appropriate) 1, 2

Special Considerations for Chronic Cough (>4 weeks)

If the cough persists beyond 4 weeks, the evaluation changes significantly:

For Wet/Productive Cough

• Consider protracted bacterial bronchitis and treat with a 2-week course of antibiotics targeting common respiratory bacteria 3
• If cough persists after 2 weeks of antibiotics, give an additional 2 weeks 3

For Dry Cough

• Consider post-infectious cough if following a recent respiratory infection 3
• Evaluate for asthma if there are associated symptoms of wheeze, exercise intolerance, or nocturnal symptoms 3
• Consider upper airway cough syndrome (post-nasal drip) 3

Common Pitfalls to Avoid

• Do not assume all wet cough is lower airway disease - upper airway conditions can also cause wet cough 5
• Do not perform chest physiotherapy - it is not beneficial and should not be performed 2
• Do not use empirical treatment approaches unless specific findings support a particular diagnosis 3
• The relationship between nasal secretions and cough is more likely linked by common etiology (infection/inflammation causing both) rather than post-nasal drip alone 1

Parental Education

• Explain that most acute cough and rhinitis in toddlers is self-limiting and due to viral infections 6, 7
• Provide information on managing fever, preventing dehydration, and identifying signs of deterioration 2
• Address parents' expectations and concerns directly 3
• Educate about the lack of efficacy and potential dangers of OTC cough and cold medications 1, 2