What is the recommended treatment for a 12-year-old with a persistent cough lasting 1 month?

Management of Persistent Throat Clearing in a 12-Year-Old After 1 Month

For a 12-year-old with persistent throat clearing lasting 1 month, the most appropriate initial approach is watchful waiting with supportive care only, as this represents either post-viral cough or nonspecific chronic cough that will resolve spontaneously in the majority of cases without any medication. 1, 2

Immediate Management - What NOT to Do

• Do not prescribe over-the-counter cough medications, antihistamines, or cough suppressants - these lack efficacy in children and carry risk of serious adverse events including morbidity and mortality 1, 2, 3
• Do not prescribe antibiotics at this stage - throat clearing without wet/productive cough, fever, or specific cough pointers does not warrant antibiotics 2
• Do not prescribe asthma medications empirically - isolated dry cough or throat clearing without wheeze, dyspnea, or documented airway obstruction does not indicate asthma, and most children with nonspecific cough do not have asthma 1, 2
• Do not prescribe GERD medications - gastroesophageal reflux is not a common cause of chronic cough in pediatric cohorts and should not be treated empirically 1

Supportive Care Measures

• Ensure adequate hydration through continued fluid intake 2
• Minimize environmental irritants, particularly tobacco smoke exposure and other pollutants 1, 2
• Elevate the head of the bed during sleep if symptoms worsen at night 2
• Use saline nasal drops if nasal congestion is contributing to post-nasal drip 2

Expected Clinical Course

• Most viral-associated coughs resolve within 7-10 days, with 90% of children cough-free by day 21 2
• At 1 month duration, this qualifies as chronic cough (>4 weeks), but the most common outcome in pediatric cohorts is natural resolution without specific diagnosis 1
• For nonspecific dry cough persisting beyond 4 weeks with no other symptoms, continue watchful waiting as most resolve spontaneously 2

When to Reassess or Escalate

Red Flags Requiring Immediate Return:

• Development of respiratory distress (increased respiratory rate, retractions, difficulty breathing) 2
• Fever develops 2
• Oxygen saturation drops below 92% 2
• Cough becomes paroxysmal with post-tussive vomiting or inspiratory "whoop" (suggests pertussis) 2
• Inability to feed or signs of dehydration 2

Specific Cough Pointers Requiring Further Evaluation:

• Digital clubbing 1, 2
• Failure to thrive or weight loss 1
• Hemoptysis 1
• Chest pain 1
• Abnormal chest examination findings (wheeze, crackles, stridor) 1
• Daily moist or productive cough develops 1

If Cough Character Changes

If the cough becomes wet/productive after 4 weeks:

• Initiate a 2-week course of antibiotics targeting common respiratory bacteria (Streptococcus pneumoniae, Haemophilus influenzae, Moraxella catarrhalis) 1, 2
• Appropriate first-line antibiotics include amoxicillin 45 mg/kg/day divided every 12 hours or 40 mg/kg/day divided every 8 hours for severe infections 4
• Alternative: azithromycin 10 mg/kg on day 1, then 5 mg/kg daily for days 2-5 5
• If wet cough persists after 2 weeks of antibiotics, prescribe an additional 2-week course 1

Diagnostic Evaluation at This Stage

At 1 month with isolated throat clearing and no cough pointers, no diagnostic testing is indicated 1, 2

Consider chest radiograph only if:

• Cough persists beyond 8 weeks 1, 6
• Any specific cough pointers develop 1, 7
• Cough becomes wet/productive and fails to respond to antibiotics 1, 7

Common Pitfalls to Avoid

• Over-diagnosing asthma in children with isolated dry cough or throat clearing - this is a frequent error that leads to unnecessary medication exposure 1, 2
• Prescribing empirical asthma medications without evidence of airway obstruction - only consider a trial of inhaled corticosteroids (beclomethasone 400 μg/day or equivalent budesonide for 2-4 weeks) if there are risk factors for asthma such as personal or family history of atopy, eczema, or allergic rhinitis 1
• Using cough suppressants like dextromethorphan - these have not been shown to be effective in children and carry risks 2
• Attributing chronic cough to GERD without evidence - unlike in adults, GERD is not a common cause in pediatric chronic cough cohorts 1

Parent Education

• Explain that throat clearing lasting 1 month is likely post-viral irritation that will resolve spontaneously in 7-10 days to 3 weeks 2, 3
• Reassure that no medication is needed or beneficial at this stage - supportive care is the appropriate evidence-based approach 2
• Provide clear instructions on warning signs requiring immediate return (respiratory distress, fever, inability to feed) 2
• Emphasize that around 80% of chronic cough cases can be diagnosed with optimal approach when needed, and treatment will be effective in 90% of those requiring intervention 3
• Address parental expectations and specific concerns directly 1