Management of Cough with Phlegm in Children
Immediate Distinction: Acute vs. Chronic Cough
The critical first step is determining if the cough has lasted more than 4 weeks—this fundamentally changes your management approach. 1
For Acute Cough (<4 weeks duration):
- Provide supportive care only and avoid all cough medications—over-the-counter cough and cold medications lack efficacy and carry risk of serious adverse events including death in children under 2 years. 2, 3, 4
- Maintain hydration through continued breastfeeding or formula feeding. 2
- Use saline nasal drops for congestion relief. 2
- Elevate the head of the bed for comfort. 2
- Minimize environmental irritants, particularly tobacco smoke exposure. 1, 2
- Do not prescribe antibiotics at initial presentation—acute cough with phlegm is typically viral. 2
Educate parents that this is likely self-limited and will resolve in 7-10 days. 2
For Chronic Cough (>4 weeks duration):
This requires a systematic, algorithm-based approach rather than empirical treatment.
Chronic Wet/Productive Cough Management Algorithm
For chronic wet cough without other concerning features (no coughing with feeding, no digital clubbing), initiate a 2-week course of antibiotics targeting common respiratory bacteria. 1 This is a Grade 1A recommendation—the strongest level of evidence. 1
Step-by-Step Antibiotic Protocol:
Initial 2-week antibiotic course targeting Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis based on local antibiotic sensitivities. 1
If cough resolves within 2 weeks: Diagnose as protracted bacterial bronchitis (PBB). 1
If wet cough persists after 2 weeks: Extend antibiotics for an additional 2 weeks (total 4 weeks). 1
If wet cough persists after 4 weeks total: Proceed to further investigations including flexible bronchoscopy with quantitative cultures and sensitivities, with or without chest CT. 1
Essential Initial Investigations:
- Obtain chest radiograph in all children with chronic cough. 1
- Perform spirometry (pre- and post-β2 agonist) when appropriate for age (typically >6 years). 1
- Do not routinely perform skin prick tests, Mantoux testing, bronchoscopy, or chest CT initially—these should be individualized based on specific clinical features. 1
Red Flags Requiring Immediate Further Investigation:
If any of these "specific cough pointers" are present, skip the antibiotic trial and proceed directly to comprehensive investigation: 1
- Coughing with feeding (suggests aspiration)
- Digital clubbing (suggests bronchiectasis or other chronic lung disease)
- Failure to thrive
- Recurrent pneumonia
- Hemoptysis
These children require flexible bronchoscopy and/or chest CT, assessment for aspiration, and evaluation of immunologic competency. 1
What NOT to Do:
Do not use empirical treatment for asthma, GERD, or upper airway cough syndrome unless specific features of these conditions are present beyond just the cough. 1 This is a Grade 1A recommendation against the "shotgun approach" commonly used in adults.
Do not prescribe acid suppression therapy solely for chronic cough without gastrointestinal symptoms (recurrent regurgitation, dystonic neck posturing in infants, heartburn/epigastric pain in older children). 1
Do not use bronchodilators, corticosteroids, or chest physiotherapy for simple wet cough—these have no proven benefit in viral bronchiolitis or upper respiratory infections. 2
Special Considerations:
Pertussis Evaluation:
Consider testing for Bordetella pertussis if the cough is paroxysmal with post-tussive vomiting or inspiratory whoop, particularly in incompletely vaccinated children. 1, 2
Asthma Assessment:
For children >6 years with chronic cough where asthma is clinically suspected (not just cough alone), consider testing for airway hyperresponsiveness. 1 However, cough as the sole symptom of asthma is unusual—there should be associated wheeze, shortness of breath, or atopic history. 5
Parent Education and Expectations:
Address parental concerns directly—parents worry most about not knowing the cause, serious illness, sleep disturbance, and permanent chest damage. 1 Exploring and addressing these specific concerns prevents parents from feeling dismissed and improves adherence to the management plan. 1
Critical Pitfall to Avoid:
The most common error is treating chronic wet cough empirically for asthma or GERD without evidence of these conditions. The presence of chronic wet/productive cough in children without underlying disease is protracted bacterial bronchitis until proven otherwise, and it responds to antibiotics in the vast majority of cases. 1 This represents a fundamental difference from adult chronic cough management and is supported by strong evidence (Grade 1A). 1