What is the treatment for a wet cough?

Treatment of Wet Cough in Children

For children with chronic wet cough (>4 weeks duration) without specific warning signs, prescribe a 2-week course of antibiotics targeting common respiratory bacteria (amoxicillin-clavulanate preferred), and if the cough persists, extend treatment for an additional 2 weeks before pursuing further investigations. 1, 2

Duration-Based Treatment Algorithm

Acute Wet Cough (<4 weeks)

• Do not prescribe antibiotics for acute wet cough unless specific bacterial infection indicators are present 2
• Provide supportive care including hydration, saline nasal drops, and head elevation 3
• Avoid over-the-counter cough medications and expectorants (including guaifenesin) as they lack efficacy in children 3
• Watchful waiting is appropriate for acute cough without bacterial infection indicators 2

Chronic Wet Cough (≥4 weeks)

Initial antibiotic therapy:

• Prescribe 2 weeks of antibiotics targeting Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis based on local antibiotic sensitivities 1
• Amoxicillin-clavulanate is the preferred first-line agent 2, 4
• If cough resolves within 2 weeks, diagnose as protracted bacterial bronchitis (PBB) 1

If cough persists after 2 weeks:

• Extend antibiotic treatment for an additional 2 weeks (total 4 weeks) 1, 2

If cough persists after 4 weeks of appropriate antibiotics:

• Pursue further investigations including flexible bronchoscopy with quantitative cultures and/or chest CT 1

Critical Assessment: Red Flag "Cough Pointers"

Immediately investigate further (regardless of duration) if any of these are present: 1

• Digital clubbing
• Coughing with feeding (suggests aspiration)
• Failure to thrive or growth failure
• Respiratory distress (retractions, grunting, nasal flaring)
• Respiratory rate >70 breaths/min in infants 5, 3
• High fever ≥39°C with toxic appearance 2, 3
• Inability to feed or persistent vomiting 3
• Cyanosis 5, 3

When to Consider Bacterial Infection in Acute Phase

Prescribe antibiotics immediately for: 2

• Confirmed bacterial pneumonia with consolidation on chest radiograph
• Acute otitis media in children under 2 years
• Severe presentation with high fever, respiratory distress, or toxic appearance
• Symptoms persisting >10 days without improvement or worsening after initial improvement 3

Special Considerations

Infants (<12 months)

• Never use honey due to infant botulism risk 5
• Higher risk for complications; maintain lower threshold for evaluation 5, 3
• Consider pertussis if paroxysmal cough with post-tussive vomiting or inspiratory "whoop" present 3

Recurrent PBB

• ≥3 episodes per year increases risk of developing bronchiectasis 4
• Consider chest CT in children with recurrent PBB, especially with Haemophilus influenzae infection 4
• Close follow-up is essential to prevent progression to bronchiectasis 4

Common Pitfalls to Avoid

• Do not prescribe antibiotics for acute wet cough <4 weeks unless specific bacterial indicators present—this is the most common error 2
• Do not use GERD treatments for chronic cough without gastrointestinal symptoms (recurrent regurgitation, heartburn, epigastric pain) 1
• Do not use asthma medications empirically unless features consistent with asthma are present 1
• Do not overlook environmental tobacco smoke exposure—address cessation with caregivers 1
• Avoid stopping antibiotics at 1 week if cough persists—complete the full 2-week course before reassessing 1, 2

Microbiologically-Confirmed PBB

• When bronchoscopy with bronchoalveolar lavage confirms ≥10⁴ CFU/mL of respiratory bacteria, use the term "microbiologically-based-PBB" (PBB-micro) to differentiate from clinically-based diagnosis 1
• This distinction is important for research purposes and recurrent cases 1