Cough Suppressants Should NOT Be Used in Pediatric Patients
Cough suppressants and over-the-counter cough medicines should not be used in children, especially young children, as they may experience significant morbidity and mortality with no demonstrated benefit. 1
Evidence-Based Recommendation
The American College of Chest Physicians (ACCP) provides a Grade D recommendation (good evidence, no benefit) explicitly stating that cough suppressants and OTC cough medicines should not be used in pediatric patients due to risk of serious adverse events including death. 1
Key Safety Concerns
Mortality risk: Infant deaths have been documented following use of cough and cold medications, with three deaths in infants under 6 months reported where these medications were determined to be the underlying cause. 2
Emergency department visits: An estimated 1,519 children under 2 years were treated in U.S. emergency departments for adverse events associated with cough and cold medications during 2004-2005. 2
Unknown toxic dosing: The dosages at which cough and cold medications cause illness or death in children under 2 years are not known, and FDA-approved dosing recommendations do not exist for this age group. 2
Age-Specific Guidance
Children Under 2 Years
The FDA does not recommend use of cough and cold products containing antihistamines or decongestants in children younger than 2 years. 3
No evidence of efficacy: Central cough suppressants (codeine, dextromethorphan) have limited efficacy in children with cough due to upper respiratory infections. 1
Children 2-14 Years
Treatment should be etiology-based, not symptom-based—identify and treat the underlying cause rather than suppressing the cough. 1
Nonspecific cough often resolves spontaneously and should be monitored for emergence of specific diagnostic indicators rather than treated with suppressants. 1
What TO Do Instead: Evidence-Based Alternatives
For Acute Viral Upper Respiratory Infections
Ipratropium bromide is the only recommended first-line treatment for persistent post-URI cough in adults (Grade A evidence), though pediatric-specific data are limited. 4
Honey can be offered for cough relief in children over 1 year of age, providing more benefit than no treatment or OTC cough medications. 5
Supportive care: Maintain hydration, manage fever with ibuprofen or acetaminophen, and address environmental irritants like tobacco smoke exposure. 1, 5
For Suspected Asthma-Related Cough
Trial of inhaled corticosteroids: In children with nonspecific cough and risk factors for asthma, a 2-4 week trial of beclomethasone 400 μg/day or equivalent budesonide may be warranted, with mandatory reevaluation. 1
Discontinue if ineffective: If cough does not resolve within the expected response time, withdraw the medication and consider other diagnoses. 1
For Chronic Productive Cough
- Investigate for underlying disease: Children with chronic productive purulent cough require evaluation for bronchiectasis, cystic fibrosis, and immune deficiency—not cough suppressants. 1
Critical Clinical Pitfalls to Avoid
Do not confuse viral bronchitis with asthma: Acute viral bronchitis should not be confused with asthma exacerbations, which may benefit from different treatments. 4
Avoid polypharmacy: Multiple caregivers administering medication increases risk of accidental overdosing when products contain overlapping ingredients. 2, 3
Do not use adult recommendations directly: Children under 14 years should be managed according to pediatric-specific guidelines when available, as etiologic factors and treatments differ from adults. 1
Address parental expectations: Determine and address specific parental concerns about the cough, as educational input addressing the child's specific condition is most successful. 1
When to Reevaluate
Reassess if symptoms worsen or do not improve within 48 hours. 5
Cough persisting beyond 4 weeks becomes "chronic cough" and requires systematic evaluation using pediatric-specific algorithms with chest radiograph and spirometry (if age-appropriate). 1, 5
Red flags requiring immediate evaluation: Respiratory distress, difficulty swallowing, drooling, toxic appearance, stridor, or oxygen saturation <92-94%. 5