What cough medicine is used in pediatric patients?

Cough Medicine for Children: Evidence-Based Recommendations

Primary Recommendation

For children with cough, honey (for those over 1 year old) is the only recommended first-line treatment, while over-the-counter cough and cold medicines should NOT be used due to lack of efficacy and potential for serious harm. 1, 2

What TO Use

Honey (First-Line Treatment)

• Honey is recommended as first-line therapy for children over 1 year of age with acute cough, showing superior efficacy compared to no treatment, diphenhydramine, or placebo 1, 2
• Honey provides more symptom relief than antihistamines but is not superior to dextromethorphan 1
• CRITICAL WARNING: Never give honey to infants under 12 months due to risk of infant botulism 1, 3, 2

Supportive Care

• Watchful waiting is appropriate for most acute coughs, as they are self-limiting viral infections 2
• Environmental modifications: eliminate tobacco smoke exposure and other irritants 4, 2

What NOT to Use

Over-the-Counter Cough and Cold Medicines

• OTC cough medicines should NOT be used in children, especially those under 4 years, as they have not been shown to reduce cough severity or duration and carry risk of significant adverse events 4, 1, 2
• These medications have little to no benefit and can cause serious morbidity and mortality 4, 1

Specific Medications to Avoid

• Codeine-containing medications must be avoided due to potential for serious side effects including respiratory distress 1, 3
• Antihistamines have minimal to no efficacy for cough relief 2
• Mucolytics and expectorants lack evidence of benefit 4

When to Investigate Further

Chronic Cough (>4 weeks duration)

• If cough persists beyond 4 weeks, systematic evaluation is required to identify specific etiologic pointers 4, 2
• Minimum workup includes chest radiograph and spirometry (if age-appropriate) 4

Red Flag "Cough Pointers" Requiring Investigation

• Coughing with feeding (suggests aspiration) 4, 2
• Digital clubbing (suggests chronic lung disease) 4, 2
• Recurrent wheeze/dyspnea (suggests asthma) 4, 2
• Wet/productive cough >4 weeks (requires antibiotics for bacterial infection) 4
• Abnormal chest radiograph or spirometry 2

Specific Clinical Scenarios

Chronic Wet/Productive Cough

• For children with chronic wet cough (>4 weeks), consider 2 weeks of antibiotics targeting common respiratory bacteria (Streptococcus pneumoniae, Haemophilus influenzae, Moraxella catarrhalis) based on local sensitivities 4
• Always investigate for bronchiectasis, cystic fibrosis, and immune deficiency 4

Post-Bronchiolitis Chronic Cough

• Manage according to general pediatric chronic cough guidelines 4
• Do NOT use asthma medications unless other evidence of asthma is present (recurrent wheeze/dyspnea) 4
• Do NOT use inhaled osmotic agents like hypertonic saline 4

Suspected Asthma with Dry Cough

• For nonspecific chronic cough with asthma risk factors, consider a 2-4 week trial of beclomethasone 400 μg/day or equivalent budesonide 4, 2
• Must re-evaluate in 2-4 weeks; discontinue if no improvement 4, 2
• Most children with nonspecific cough do NOT have asthma 4

GERD-Related Cough

• Do NOT use GERD treatments (PPIs, H2 blockers) when there are no GI symptoms (no regurgitation, heartburn, or epigastric pain) 4, 2
• Acid suppressive therapy should NOT be used solely for chronic cough 4
• If GI symptoms are present, treat according to GERD-specific guidelines for 4-8 weeks and re-evaluate 4

Critical Follow-Up Requirements

Mandatory Re-evaluation Timeframes

• All children started on medication must be re-evaluated within 2-4 weeks 4, 2
• If no improvement within expected timeframe, discontinue medication and reconsider diagnosis 4, 2
• Children with nonspecific cough should be monitored for emergence of specific diagnostic pointers 4, 2

When to Seek Immediate Medical Attention

• Difficulty breathing or increased work of breathing 1, 3
• Fever that persists or appears later in illness 1
• Changes in mental status or refusal to eat/drink 1, 3

Common Pitfalls to Avoid

• Using adult cough management approaches in children - pediatric causes and treatments differ significantly 4
• Prescribing OTC medications due to parental pressure despite lack of evidence 4, 2
• Failing to discontinue ineffective medications 4, 2
• Using asthma medications without clear evidence of asthma 4, 2
• Prolonged use of antibiotics without documented bacterial infection 2

Parental Counseling

• Address parental expectations and specific concerns about the cough 4, 2
• Explain that most acute coughs are self-limiting viral infections 2
• Educate about the natural course and expected resolution timeframes 2
• Discuss environmental modifications, particularly tobacco smoke cessation 4, 2