What is the best treatment for cough in pediatric patients?

Best Treatment for Cough in Pediatric Patients

Honey (for children over 1 year) is the only evidence-based first-line treatment for acute cough in children, while over-the-counter cough medications should be avoided entirely due to lack of efficacy and potential harm. 1

First-Line Treatment Approach

For Acute Cough (< 4 weeks)

Honey is the recommended treatment for children over 1 year of age, providing superior relief compared to no treatment, diphenhydramine, or placebo. 1, 2 This recommendation comes from the American Academy of Pediatrics and represents the strongest evidence-based intervention for symptomatic cough relief. 1

• Never give honey to infants under 12 months due to risk of infant botulism 1
• Most acute coughs are self-limiting viral infections requiring only supportive care and watchful waiting 1, 2

For Chronic Cough (> 4 weeks)

All children with chronic cough require thorough clinical evaluation to identify specific underlying causes rather than empirical symptomatic treatment. 1, 2

• Obtain chest radiograph and spirometry (if age-appropriate) for all children with chronic cough 1
• Distinguish between specific cough (with pointers to underlying disease like wheezing, digital clubbing, or abnormal imaging) and nonspecific cough (dry cough without specific indicators) 2

Medications That Must Be AVOIDED

Over-the-Counter Cough Medications

OTC cough and cold medicines should NOT be used in children as they have not been shown to reduce cough severity or duration. 1, 3 The evidence against their use is compelling:

• Children under 4 years: Absolute contraindication due to potential toxicity and lack of efficacy 3
• Children 4-6 years: Should generally be avoided per FDA advisory committees 3
• Between 1969-2006, there were 54 deaths from decongestants and 69 deaths from antihistamines in children under 6 years 3
• OTC medications are common causes of unintentional poisoning in children under 5 years 3

Specific Agents to Avoid

Antihistamines have minimal to no efficacy for cough relief in children and are associated with adverse events. 4, 1 Systematic reviews demonstrate that antihistamine-decongestant combinations are no more effective than placebo for acute cough in children. 4

Dextromethorphan should not be used in pediatric patients, as the American Academy of Pediatrics specifically advises against its use for any type of cough in children. 1 Studies show it is no different than placebo in reducing nocturnal cough or sleep disturbance. 4

Codeine-containing medications must be avoided due to potential serious side effects including respiratory distress. 1, 2 In 2018, the FDA restricted prescription opioid cough medicines to adults ≥18 years only. 3

Disease-Specific Treatment Considerations

When Asthma is Suspected

If risk factors for asthma are present with chronic nonspecific cough, consider a trial of low-dose inhaled corticosteroids (400 μg/day budesonide or beclomethasone equivalent) for 2-3 weeks. 4, 2

• Reassess after 2-3 weeks - cough unresponsive to ICS should NOT be treated with increased doses 4
• If cough resolves, the child should be reevaluated after stopping treatment, as resolution may be spontaneous rather than treatment-related 4
• Do not use bronchodilators (like salbutamol) for cough without evidence of airflow obstruction 3

When Bacterial Infection is Suspected

Antimicrobials should be restricted to specific clinical scenarios:

• High fever ≥38.5°C persisting > 3 days warrants consideration of beta-lactam antibiotics 1
• Radiologically confirmed pneumonia in children under 3 years: Use amoxicillin 80-100 mg/kg/day in three divided doses 1, 5
• Persistent nasal discharge or confirmed sinusitis: A 10-day antimicrobial course reduces cough persistence, though number needed to treat is 8 4
• Acute cough from common colds: Antimicrobials provide no benefit 4

When GERD is Suspected

GERD treatments should NOT be used when there are no clinical features of gastroesophageal reflux. 2 Only consider GERD-specific treatment for children with chronic cough AND gastrointestinal symptoms, treating for 4-8 weeks with reassessment. 2

Critical Follow-Up Requirements

Mandatory reassessment is essential to avoid common pitfalls:

• Review children who are deteriorating or not improving after 48 hours 1
• Re-evaluate all children with persistent cough at 2-4 weeks for emergence of specific etiological pointers 1, 2
• Discontinue medications if no effect is observed within the expected timeframe 1, 2
• Consider specialist referral if cough persists despite appropriate management 2

Environmental Modifications

Evaluate and address environmental triggers in all children with cough:

• Tobacco smoke exposure 1, 2
• Air pollutants and allergens 2
• Parental education about natural course and expected resolution timeframes 2

Common Pitfalls to Avoid

• Prescribing OTC medications due to parental pressure despite lack of efficacy 1
• Using adult cough management approaches in pediatric patients 1, 2
• Empirical treatment for asthma or GERD without clinical features consistent with these conditions 1, 2
• Prolonged use of asthma medications without clear evidence of asthma 2
• Failure to re-evaluate children whose cough persists despite treatment 1, 2
• Assuming all cough represents asthma and treating with bronchodilators without evidence of airflow obstruction 3