What is the evidence-based management of cough in pediatrics?

Evidence-Based Management of Cough in Pediatrics

Critical First Principle: Avoid Over-the-Counter Cough Medications

Cough suppressants and over-the-counter cough medicines should NOT be used in children with cough, as they offer no symptomatic relief and may cause significant morbidity and mortality, especially in young children. 1

• OTC antitussive medications should not be routinely used in children under 2 years of age 2
• These medications have limited proven efficacy in children under 6 years 3
• Despite generating billions in annual sales, there is a lack of evidence for their efficacy and multiple FDA warnings exist 2
• The risk of inappropriate prescribing, accidental overdosing, and adverse events outweighs any theoretical benefit 4

Diagnostic Approach: Differentiate by Cough Duration and Characteristics

Acute Cough (< 4 weeks)

• Most acute cough is self-limiting and results from viral upper respiratory infections 5
• Management follows a "wait, watch, review" approach 5
• Educate parents on expected illness duration (typically resolves within days to 2 weeks) and risks of OTC medications 5

Chronic Cough (≥ 4 weeks)

• Define the etiology first, then treat based on the specific cause—this is the cornerstone of pediatric cough management 1
• Distinguish between dry versus moist (productive) cough, as this guides further evaluation 1

Management Algorithm by Cough Type

Nonspecific Cough (Dry, No Clear Etiology)

Step 1: Watchful Waiting with Environmental Modification

• Many cases resolve spontaneously within 2-4 weeks without treatment 6
• Address tobacco smoke exposure, dust, and pet allergens—these environmental factors are more important than medication 6
• Reevaluate for emergence of specific etiologic pointers 1

Step 2: Consider Inhaled Corticosteroid Trial ONLY if Asthma Risk Factors Present

• Risk factors include: personal history of atopy/allergic sensitization, family history of asthma, presence of wheeze, or documented airflow obstruction on spirometry 6
• Most children with nonspecific cough do NOT have asthma 1, 6
• If trial warranted: beclomethasone 400 μg/day or equivalent budesonide for 2-4 weeks maximum 1, 6
• Mandatory reassessment at 2-4 weeks—if no response, withdraw medication and reconsider diagnosis 1, 6

Critical Pitfall: Oral steroids have no proven benefit for nonspecific cough and may actually increase hospitalizations 6

Chronic Productive/Moist Cough

Always investigate for underlying serious pathology:

• Document presence or absence of bronchiectasis 1
• Identify treatable causes: cystic fibrosis, immune deficiency 1
• Consider role of antibiotics in children with chronic moist cough or post-viral chronic cough 1

Cough with Upper Airway Symptoms

• Evaluate for upper airway cough syndrome (previously postnasal drip) secondary to rhinosinusitis or allergic rhinitis 1
• Consider antimicrobials if persistent nasal discharge or radiographically confirmed sinusitis 6

Cough with Suspected Asthma

• Treat with asthma-specific therapy (beta-agonists, inhaled corticosteroids) rather than nonspecific cough medications 7
• For acute asthma exacerbation: systemic corticosteroids (oral dexamethasone or prednisolone) are indicated 6

Cough with Suspected GERD

• Relationship between cough and GERD requires objective criteria for diagnosis 1
• Treatment should target GERD specifically if confirmed 1

Safe Symptomatic Measures

For cough relief:

• Honey can be offered for children over 1 year of age—provides more benefit than no treatment or OTC medications 3

For associated pain/fever:

• Ibuprofen or paracetamol (acetaminophen) for symptomatic relief 3

Medication Trial Principles

If any medication is started:

• Define expected response time upfront 1
• If cough does not resolve within expected timeframe, withdraw medication and reconsider other diagnoses 1
• Do not continue ineffective treatments or escalate doses without clear benefit 6

Red Flags Requiring Immediate Evaluation

• Respiratory distress 3
• Difficulty swallowing or drooling 3
• Toxic appearance 3
• Stridor 3
• Oxygen saturation <92-94% 3

Special Considerations

Age-specific guidance:

• Children should be managed according to pediatric-specific guidelines when available, as etiologic factors and treatments differ from adults 1
• In children ≤14 years, use adult recommendations with caution only when pediatric-specific recommendations are unavailable 1

Parental counseling:

• Determine and address parental expectations and specific concerns 1
• Educate about managing fever, maintaining hydration, and recognizing signs of deterioration 3
• Reassess if symptoms worsen or do not improve within 48 hours 3

Key Evidence Gaps

The American College of Chest Physicians acknowledges large gaps in knowledge regarding evidence-based pediatric cough management, particularly concerning optimal definitions of acute/subacute/chronic cough, natural history of nonspecific cough, and role of antibiotics in chronic moist cough 1