Management of Cough and Cold in Infants Less Than 6 Months Old
Do not use over-the-counter cough and cold medications in infants under 6 months of age—these medications lack proven efficacy and carry serious risks including death. 1, 2
Why OTC Medications Are Contraindicated
The American Academy of Pediatrics explicitly recommends against OTC cough and cold medications in this age group based on compelling safety data 1:
- Between 1969-2006, there were 43 deaths from decongestants in infants under 1 year and 41 deaths from antihistamines in children under 2 years 1, 2
- Major pharmaceutical companies voluntarily removed these products for children under 2 years from the market in 2007 1, 2
- Topical decongestants have a narrow therapeutic window in infants under 1 year, creating unacceptable risk for cardiovascular and CNS toxicity 1, 2
- No FDA-approved dosing recommendations exist for this age group 3
Recommended Supportive Care Measures
Focus exclusively on supportive care, which is both safe and effective 1:
- Gentle nasal suctioning to clear secretions and improve breathing 1
- Maintain adequate hydration through continued breastfeeding or formula feeding to help thin secretions 1
- Use a supported sitting position during feeding and rest to help expand lungs and improve respiratory symptoms 1
- Administer acetaminophen for fever and discomfort using weight-based dosing, which can help reduce coughing episodes 1
Red Flag Symptoms Requiring Immediate Medical Attention
Parents must seek emergency care if any of these warning signs appear 1, 2:
- Respiratory rate >70 breaths/minute 1, 2
- Difficulty breathing, grunting, or cyanosis (blue discoloration) 1, 2
- Oxygen saturation <92% 1, 2
- Poor feeding or signs of dehydration (decreased wet diapers, sunken fontanelle, no tears when crying) 1, 2
- Persistent high fever (rectal temperature ≥100.4°F/38°C in infants under 3 months) 1
When to Consider Bacterial Infection
Do not prescribe antibiotics for viral upper respiratory infections, which represent the vast majority of coughs and colds in this age group 1:
- If bacterial pneumonia is suspected based on clinical findings (high fever, tachypnea, hypoxia, rales), amoxicillin is first-choice for children under 5 years 1, 2
- Most acute coughs are viral and self-limited, resolving within 1-3 weeks 2
Special Consideration: Pertussis
Infants under 6 months are at highest risk for severe pertussis complications and death 1:
- Consider pertussis if there is paroxysmal cough, post-tussive vomiting, or inspiratory whoop 4
- Azithromycin is the preferred macrolide for infants under 1 month due to lower risk of infantile hypertrophic pyloric stenosis compared to erythromycin 1
- For infants 1-5 months, azithromycin or clarithromycin are first-line agents 1
When Cough Becomes Chronic (>4 Weeks)
If cough persists beyond 4 weeks, transition to a systematic chronic cough evaluation 4:
- Obtain chest radiograph 4
- Use pediatric-specific cough management protocols based on whether cough is wet/productive versus dry 4
- Look for specific cough pointers: coughing with feeding, digital clubbing, failure to thrive 4
- For chronic wet cough without specific pointers, consider a 2-week trial of antibiotics targeting Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis 4
Prevention Strategies
Emphasize preventive measures to reduce illness burden 1:
- Hand hygiene with soap and water to prevent transmission of respiratory viruses 1
- Minimize exposure to tobacco smoke and other environmental irritants 1
- Ensure household contacts are up-to-date on pertussis vaccination 1
Common Pitfalls to Avoid
- Never use honey in infants under 12 months due to botulism risk (though honey may help in older children with acute cough) 4
- Avoid codeine-containing medications because of potential for serious side effects including respiratory distress 4
- Do not use empirical asthma treatment unless other features consistent with asthma are present 4
- Chest physiotherapy is not beneficial and should not be performed 2