Guidelines for Treating Post-Infectious Cough in Children
Post-infectious cough in children is self-limited and requires no specific treatment in most cases, with antibiotics having no role unless pertussis or bacterial sinusitis is confirmed. 1
Diagnostic Approach
Post-infectious cough is a clinical diagnosis of exclusion that should be considered when cough persists for 3-8 weeks following an acute respiratory infection. 1
Key Diagnostic Considerations:
Children under 5 years have 3.8-5 respiratory infections per person per year, making post-infectious cough extremely common, especially in daycare settings. 1
Common causative organisms include respiratory syncytial virus, influenza, parainfluenza, adenovirus, Mycoplasma pneumoniae, Chlamydophila pneumoniae, Moraxella catarrhalis, and Bordetella pertussis. 1
Prolonged cough after Mycoplasma and Chlamydophila infections occurs in 28% and 57% of young children respectively, with cough lasting >21 days. 1
If cough persists beyond 8 weeks, you must reconsider the diagnosis and evaluate for other causes including upper airway cough syndrome, asthma, gastroesophageal reflux disease, protracted bacterial bronchitis, or foreign body aspiration. 1, 2
Treatment Algorithm
First-Line Management: Watchful Waiting
The cornerstone of treatment is reassurance and expectant management, as post-infectious cough resolves spontaneously in time. 1
Antibiotics have no role in treating post-infectious cough, as bacterial infection does not play a role in the pathogenesis. 1
Over-the-counter cough medications are ineffective for symptomatic relief in children and should not be used. 3, 4
When to Consider Specific Interventions:
For protracted and persistently troublesome cough that significantly impacts quality of life, consider the following stepwise approach:
Step 1: Inhaled Ipratropium
- Trial of inhaled ipratropium bromide may attenuate the cough based on one small controlled trial in adults. 1
- This recommendation is extrapolated from adult data, as pediatric-specific evidence is lacking. 1
Step 2: Inhaled Corticosteroids
- Consider inhaled corticosteroids (such as fluticasone propionate) when cough adversely affects quality of life and persists despite ipratropium. 1
- The rationale is that post-infectious cough results from airway inflammation with neutrophil transmigration, though clinical data in humans are limited. 1
Step 3: Oral Corticosteroids (Severe Cases Only)
- For severe paroxysms of cough, consider a brief course of oral corticosteroids: prednisone 30-40 mg daily (or equivalent), tapering to zero over 2-3 weeks. 1
- This is based on uncontrolled studies and should only be used after ruling out other common causes of chronic cough. 1
Special Consideration: Pertussis
Suspect Bordetella pertussis when cough is accompanied by paroxysms, post-tussive vomiting, or inspiratory whooping sound. 1, 2
Pertussis-Specific Management:
Macrolide antibiotics are indicated when pertussis is confirmed or highly suspected, but only if started within the first 2 weeks of infection. 1
Early treatment diminishes coughing paroxysms and prevents disease transmission, requiring patient isolation for 5 days from treatment start. 1
Treatment beyond 2 weeks is unlikely to benefit the patient, though it may still reduce transmission. 1
Long-acting β-agonists, antihistamines, corticosteroids, and pertussis immunoglobulin have no role in treating pertussis cough. 1
Critical Pitfalls to Avoid
Do not use antibiotics empirically for post-infectious cough without confirmed bacterial sinusitis or pertussis. 1, 2
Do not diagnose "cough variant asthma" in children with isolated chronic cough, as this is rarely the cause in pediatric populations. 3
Do not prescribe centrally acting antitussives (codeine, dextromethorphan) as first-line therapy; reserve these only when other measures fail. 1
Do not overlook back-to-back infections in winter months or coinfections, which can prolong coughing periods significantly. 1
Do not assume treatment response in medication trials is due to the medication itself, given the favorable natural history of post-infectious cough. 3
When to Reassess
Reassess within 4-6 weeks if symptoms are not improving, and if cough persists beyond 8 weeks, reclassify as chronic cough and pursue further evaluation for alternative diagnoses. 2