What is the recommended treatment for a cough in a 13-year-old?

Treatment of Cough in a 13-Year-Old

For a 13-year-old with cough, avoid over-the-counter cough medicines and codeine-containing medications, as they lack efficacy and carry risks of serious side effects including respiratory distress; instead, use honey for acute cough or pursue etiology-based treatment for chronic cough lasting more than 4 weeks. 1

Initial Assessment: Acute vs. Chronic Cough

• Define the duration: Cough lasting less than 4 weeks is acute; cough lasting 4 weeks or longer is chronic and requires systematic evaluation 1
• For acute cough (likely viral), most cases are self-limiting and benign, requiring only supportive care 1
• For chronic cough, determine if it is specific (with pointers to underlying disease like wheezing, digital clubbing, or abnormal chest X-ray) or non-specific (dry cough without indicators) 2

Treatment for Acute Cough (< 4 weeks)

First-Line Approach

• Honey is the recommended first-line treatment for children over 1 year of age, providing more relief than diphenhydramine, placebo, or no treatment 1, 2
• Simple home remedies like honey and lemon are as effective as pharmacological treatments and should be considered first 1, 3

What NOT to Use

• Do not prescribe over-the-counter cough and cold medicines - they have not been shown to reduce cough severity or duration and may cause significant morbidity and mortality 1
• Avoid codeine-containing medications due to potential serious side effects including respiratory distress 1, 2
• Antihistamines have minimal to no efficacy for cough relief in children 2
• Cough suppressants should not be used, especially in young children 1

Alternative Options (if needed)

• Dextromethorphan may be considered for short-term symptomatic relief (typically less than 7 days), though standard OTC dosing (15-30 mg) is often subtherapeutic; maximum suppression occurs at 60 mg 3, 4
• Menthol by inhalation provides acute but short-lived cough suppression 1, 3

Treatment for Chronic Cough (≥ 4 weeks)

Systematic Evaluation Required

• Obtain chest radiograph and spirometry (pre- and post-β2 agonist when age-appropriate) 1
• Look for specific cough pointers: wheezing (suggests asthma), digital clubbing, coughing with feeding, productive/wet cough, or abnormal imaging 1, 2
• Examine the ears for foreign material or structures touching the eardrum (Arnold's nerve reflex) 1

Etiology-Based Treatment Algorithm

For Non-Specific Chronic Cough:

• If cough does not resolve within 2-4 weeks, re-evaluate for emergence of specific etiological pointers 1, 2
• When risk factors for asthma are present (family history, atopy, exercise-induced symptoms), consider a short 2-4 week trial of beclomethasone 400 μg/day or equivalent budesonide dose 1, 2
• Always re-evaluate in 2-4 weeks - if no response, discontinue the medication and consider other diagnoses 1
• Do not increase ICS doses if cough is unresponsive 1

For Specific Diagnoses:

• Asthma-related cough: Inhaled corticosteroids are effective; response typically occurs within 2-7 days 1
• Gastroesophageal reflux with GI symptoms: Treat according to GERD guidelines for 4-8 weeks, then re-evaluate 2
• Do NOT use empirical GERD treatment without clinical features of reflux 1, 2
• Tuberculosis risk: Screen regardless of cough duration in high TB prevalence settings 1

Critical Pitfalls to Avoid

• Never use prolonged inhaled corticosteroids without clear evidence of asthma - resolution may be due to spontaneous improvement rather than treatment effect 1
• Do not use antibiotics for non-bacterial causes of cough 2
• Avoid empirical treatment for upper airway cough syndrome, GERD, or asthma unless specific features of these conditions are present 1
• Always discontinue medications if no effect within expected timeframe (2-4 weeks for ICS trial) 1
• Do not apply adult cough management approaches to pediatric patients - etiologies and treatments differ 1, 2

Environmental Modifications

• Evaluate and eliminate tobacco smoke exposure - this is a critical intervention 1, 2
• Assess for air pollutants and allergens 2

Follow-Up Requirements

• All children with chronic cough must be re-evaluated within 2-4 weeks 1, 2
• If medications are started, assess response within the expected timeframe and discontinue if ineffective 1, 2
• Educate parents about natural course and expected resolution timeframes 2
• Consider specialist referral if cough persists despite appropriate management 2