What is the best treatment approach for a toddler with Upper Respiratory Tract Infection (URTI) symptoms, including a cough that worsens when lying down and results in frequent waking?

Management of Toddler with URTI and Nocturnal Cough

This is a typical post-viral cough following URTI that requires watchful waiting and supportive care only—no antibiotics, no cough suppressants, and no asthma medications unless specific features of asthma are present. 1, 2

Understanding the Clinical Picture

• Post-viral cough commonly persists for 1-3 weeks after URTI, with 10% of children still coughing at 25 days, and cough worsening when lying down is a normal pattern that does not indicate bacterial infection or asthma 1
• The presence of cough that disrupts sleep is expected and occurs in 88% of children with acute URTI-related cough, also disturbing parents' sleep in 72% of cases 3
• Nasal discharge in viral URIs typically progresses from clear to thick mucoid to purulent over several days—this purulent phase is normal viral progression and does not indicate bacterial superinfection requiring antibiotics 2

Primary Management Approach

Reassurance and watchful waiting are the cornerstone of management:

• Reassure parents that post-URTI cough can persist for up to 4 weeks without indicating a serious condition, and the American College of Chest Physicians recommends watchful waiting as the primary approach since spontaneous resolution typically occurs within 1-2 weeks 1
• Provide supportive care with adequate hydration and rest 2
• Use acetaminophen or ibuprofen for fever or discomfort if present 2

What NOT to Prescribe

Critical pitfalls to avoid:

• Do not prescribe antibiotics—they are not indicated for uncomplicated viral URIs and provide no benefit for viral illness 4, 2
• Do not prescribe cough suppressants (including dextromethorphan or codeine)—there is no evidence of benefit for cough medications in children, and over-the-counter cough and cold medications should not be used in children younger than four years due to potential harm 4, 5, 6
• Do not prescribe mucolytics or expectorants—they lack evidence of benefit in uncomplicated viral URIs 2
• Do not start asthma medications empirically—avoid trials of asthma medications unless there are other features consistent with asthma such as recurrent wheeze or dyspnea responsive to beta-2 agonists 1

When to Reassess

Schedule follow-up or advise parents to return if:

• Cough persists beyond 4 weeks—this warrants further evaluation including consideration of chest radiograph and spirometry 1
• Symptoms persist beyond 10 days without any improvement 2
• Symptoms worsen after initial improvement (worsening course) 2
• High fever (≥39°C) with purulent nasal discharge persists for 3+ consecutive days (severe onset criteria for possible bacterial sinusitis) 4, 2
• Cough becomes spasmodic or is associated with post-tussive vomiting—consider pertussis testing even in vaccinated children 1
• New concerning symptoms develop or the child's condition deteriorates 2

Key Clinical Distinction

• The presence of purulent nasal discharge alone does NOT meet criteria for bacterial sinusitis and should not trigger antibiotic prescription—this is the most common prescribing error 4, 2
• Bacterial sinusitis requires one of three specific patterns: (1) persistent symptoms not improving by 10 days, (2) worsening symptoms after initial improvement, or (3) severe symptoms with fever ≥39°C and purulent discharge for at least 3 consecutive days 4