What is the first line treatment for a cough in a 15-month-old child?

Treatment of Cough in a 15-Month-Old Child

For a 15-month-old with cough, avoid over-the-counter cough medications entirely and focus on supportive care for acute cough, while systematically evaluating for specific causes if the cough persists beyond 4 weeks. 1, 2

Immediate Management Approach

If Acute Cough (Less Than 4 Weeks)

Provide supportive care only—no medications:

• Ensure adequate hydration to help thin secretions 2
• Use saline nasal drops for nasal congestion relief 2
• Elevate the head of the bed during sleep to improve breathing 2
• Do NOT use over-the-counter cough medications (dextromethorphan, antihistamines, decongestants) as they lack efficacy and carry risk of serious adverse effects in young children 3, 1, 2

Critical Red Flags Requiring Immediate Evaluation

Monitor closely and seek immediate medical attention if the child develops:

• Respiratory distress (respiratory rate >70 breaths/min, difficulty breathing, grunting, retractions) 3, 2
• Oxygen saturation <92% or cyanosis 3
• High fever ≥39°C (102.2°F) 2
• Not feeding or signs of dehydration 3
• Change in sputum from clear to yellow/green (purulent) 2
• Paroxysmal cough with post-tussive vomiting or inspiratory "whoop" suggesting pertussis 2

Evaluation for Chronic Cough (Persisting Beyond 4 Weeks)

Use a systematic, etiology-based approach rather than empirical treatment:

Determine Cough Characteristics

Wet/productive cough suggests:

• Prolonged bacterial bronchitis (most common)—treat with amoxicillin 45 mg/kg/day divided every 12 hours for 2 weeks 1, 2
• Foreign body aspiration—look for history of choking episode, unilateral wheezing, decreased breath sounds 1
• Consider chest radiograph to rule out pneumonia or structural abnormalities 3, 1

Dry cough suggests:

• Post-infectious cough (most common, self-limited)
• Cough-variant asthma—consider if there are risk factors (atopy, family history, nocturnal pattern) 1
• Pertussis—look for paroxysmal pattern with post-tussive vomiting 1

Essential Diagnostic Steps

• Obtain chest radiograph for any chronic cough 3, 1
• Assess for "specific cough pointers": history of choking, coughing with feeding (aspiration), digital clubbing, failure to thrive 1
• Test for pertussis if clinically suspected (paroxysmal cough pattern) 3, 1

Treatment Based on Specific Etiology

For Prolonged Bacterial Bronchitis (Wet Cough >4 Weeks)

Amoxicillin is first-line therapy:

• Dose: 45 mg/kg/day divided every 12 hours for 2 weeks initially 1, 2
• Targets common respiratory bacteria: Streptococcus pneumoniae, Haemophilus influenzae, Moraxella catarrhalis 2
• If cough persists, extend treatment to 4 weeks total 2
• Reassess if no improvement after 48-72 hours 2

For Suspected Cough-Variant Asthma (Dry Cough with Risk Factors)

Consider a time-limited therapeutic trial:

• Inhaled corticosteroid: beclomethasone 400 mcg/day or equivalent budesonide for 2-4 weeks 3, 1
• Only use if specific features suggest asthma (atopy, family history, nocturnal pattern, response to bronchodilators) 1
• Discontinue if no response within 2-4 weeks—most children with nonspecific cough do not have asthma 3, 1

What NOT to Do

Avoid these common pitfalls:

• Never use empirical treatment for upper airway cough syndrome, GERD, and asthma simultaneously without specific clinical features 3, 1
• Do not treat GERD empirically unless there are gastrointestinal symptoms (recurrent regurgitation, heartburn) 1
• Avoid oral corticosteroids for nonspecific cough—no benefit and potential harm 1
• Do not routinely perform skin prick tests, CT scans, or bronchoscopy unless specific clinical indicators are present 3, 1

Follow-Up Strategy

Mandatory reassessment timeline:

• Review at 48 hours if started on antibiotics and not improving 3, 2
• Re-evaluate at 2-4 weeks if on therapeutic trial for asthma 3, 1
• If cough persists beyond 4 weeks despite appropriate treatment, reconsider diagnosis and refer for specialist evaluation 3, 1

Environmental Interventions

• Eliminate exposure to tobacco smoke and other environmental irritants 3
• Address parental concerns and expectations directly, explaining that most acute coughs are self-limited viral illnesses 3

The key principle is that treatment must be etiology-specific, not symptom-based, and over-the-counter cough medications should never be used in this age group due to lack of efficacy and potential for serious harm. 3, 1, 2