What is the appropriate management for a cough in children?

Management of Cough in Children

For children with chronic wet/productive cough lasting >4 weeks without specific cough pointers, treat with a 2-week course of antibiotics targeting common respiratory bacteria (Streptococcus pneumoniae, Haemophilus influenzae, Moraxella catarrhalis), and if cough persists, extend treatment for an additional 2 weeks. 1, 2

Initial Assessment: Acute vs. Chronic Cough

• Define the duration: Cough lasting >4 weeks is considered chronic and requires systematic evaluation using pediatric-specific algorithms 1, 2
• Characterize the cough: Determine if the cough is wet/productive versus dry, as this fundamentally changes the diagnostic and treatment approach 1, 2
• Identify specific cough pointers that indicate serious underlying disease requiring immediate investigation 1:
  • Coughing with feeding, digital clubbing, failure to thrive 1, 2
  • Hemoptysis, daily moist cough, recurrent pneumonia 1
  • Cardiac abnormalities, immunodeficiency, neurodevelopmental abnormality 1
  • Abnormal chest examination findings (stridor, wheeze, crackles) 1

Management Algorithm Based on Cough Type

For Chronic Wet/Productive Cough (>4 weeks)

Without specific cough pointers:

• Start antibiotics immediately: Prescribe a 2-week course targeting S. pneumoniae, H. influenzae, and M. catarrhalis based on local antibiotic sensitivities 1, 2
• If cough resolves within 2 weeks: Diagnose as protracted bacterial bronchitis (PBB) 1, 2
• If cough persists after 2 weeks: Extend antibiotic treatment for an additional 2 weeks 1, 2
• If cough persists after 4 weeks total: Perform chest radiograph, spirometry (if age-appropriate), and consider flexible bronchoscopy or chest CT to evaluate for bronchiectasis or structural abnormalities 1

With specific cough pointers:

• Obtain chest radiograph and spirometry immediately 1, 2
• Initiate investigations based on specific clinical features (e.g., sweat test for cystic fibrosis, immune workup, TB testing) 1

For Chronic Dry/Non-Productive Cough (>4 weeks)

• Evaluate for asthma if associated with wheeze, exercise intolerance, nocturnal symptoms, or family history of atopy 2, 3
• Perform spirometry (if age >6 years) and assess for airway hyperresponsiveness 1, 2
• Consider post-infectious cough if following recent respiratory infection 2, 4
• Evaluate for upper airway cough syndrome (post-nasal drip) 2
• Avoid empirical asthma treatment unless other features consistent with asthma are present 1, 2
• If asthma is suspected with risk factors, consider a short trial of inhaled corticosteroids with defined duration to confirm or refute diagnosis 2

For Acute Cough (<4 weeks)

Children >1 year old:

• Honey is first-line treatment for symptomatic relief, as it provides more relief than diphenhydramine or placebo 2
• Do NOT prescribe over-the-counter cough and cold medications - they have not been shown to reduce cough severity or duration 2
• Avoid codeine-containing medications due to risk of serious side effects including respiratory distress 2

Children <2 years old:

• Absolutely avoid OTC cough and cold medications due to lack of efficacy and potential for serious toxicity, including multiple reported fatalities 5
• Provide supportive care: adequate hydration, antipyretics for comfort, nasal suctioning if needed 5
• Educate families on managing fever, preventing dehydration, and identifying signs of deterioration 5

First-Line Investigations for Chronic Cough

• Chest radiograph: Obtain for all children with chronic cough to assess for structural abnormalities 1, 2
• Spirometry: Perform when age-appropriate (typically >6 years) to assess airway reactivity 1, 2
• Do NOT routinely perform additional tests (skin prick testing, Mantoux, bronchoscopy, chest CT) unless specifically indicated by clinical findings 2

Critical Pitfalls to Avoid

• Never use empirical treatment approaches not based on specific findings or suspected diagnoses 1, 2
• Do not assume adult causes of chronic cough apply to children - age and clinical setting must guide evaluation 1
• Avoid OTC cough medications in children, especially those <6 years, due to lack of efficacy and safety concerns 2, 5
• Do not delay antibiotic treatment for chronic wet cough without specific pointers - early treatment prevents progression to bronchiectasis 1
• Never ignore environmental tobacco smoke exposure - identify and counsel on cessation 2

When to Refer to Specialist

• Cough persisting after appropriate initial management (4 weeks of antibiotics for wet cough) 1, 6
• Presence of concerning symptoms: hemoptysis, weight loss, persistent focal findings 2, 6
• Recurrent episodes despite appropriate treatment 2
• Suspected anatomical abnormality requiring specialized evaluation 2
• Unexplained chronic cough that does not fit standard diagnostic categories 6

Special Populations

First Nations children:

• Consider high-risk group requiring culturally specific management strategies 6
• Lower threshold for investigation and specialist referral 6

Infants <2 months:

• Most dry cough is post-viral from upper respiratory infection 5
• Consider bronchiolitis if accompanied by wheezing 5
• If cough persists >3-4 weeks, initiate formal chronic cough workup including chest radiograph 5