Management of Acute Cough in Pediatrics
Primary Recommendation
Do not use over-the-counter cough and cold medications in children, as they provide no symptomatic benefit and carry significant risk of morbidity and mortality. 1
First-Line Treatment Approach
For Children Over 1 Year of Age
- Honey is the recommended first-line treatment, providing more relief than no treatment, diphenhydramine, or placebo 2, 3
- Typical dosing: 2.5-5 mL as needed for cough symptoms 2
- Never give honey to infants under 12 months due to risk of infant botulism 2, 3
For Infants Under 1 Year
- Supportive care only with "wait, watch, review" approach 4
- Ensure adequate hydration and humidified air 4
- Address parental expectations and provide reassurance about self-limited nature 1
Medications to Absolutely Avoid
Cough Suppressants and OTC Medications
- Cough suppressants and OTC cough medicines should not be used as they may cause significant morbidity and mortality 1
- Dextromethorphan is no better than placebo for nocturnal cough or sleep disturbance 2
- Between 1969-2006, there were 54 deaths from decongestants and 69 deaths from antihistamines in children under 6 years 5
Specific Contraindications
- Codeine-containing medications must be avoided due to potential respiratory distress 2, 3
- Antihistamines have minimal to no efficacy and are associated with adverse events 2
- Beta-2 agonists (like salbutamol) have no evidence supporting use in acute cough without airflow obstruction 5
When Antibiotics Are Indicated
Consider Antibiotics If:
- High fever (≥38.5°C) persisting for more than 3 days 2
- Clinically and radiologically confirmed pneumonia: use amoxicillin 80-100 mg/kg/day in three divided doses 2
- Associated purulent acute otitis media 2
- Persistent nasal discharge or confirmed sinusitis: 10-day antimicrobial course (number needed to treat = 8) 2
Do NOT Use Antibiotics For:
- Acute cough from common colds, as antimicrobials provide no benefit 2
Re-evaluation Timeline
Mandatory Follow-Up Points
- Review if deteriorating or not improving after 48 hours 2
- Re-evaluate at 2-4 weeks if cough persists to assess for specific etiologic pointers 1, 2, 3
- If medication trial initiated, withdraw if no response within expected timeframe and consider other diagnoses 1
Special Consideration: Asthma Risk Factors
Trial of Inhaled Corticosteroids
- For children with nonspecific cough AND risk factors for asthma, consider 2-4 week trial of beclomethasone 400 μg/day or equivalent budesonide 1, 2
- Most children with nonspecific cough do not have asthma 1
- Always re-evaluate in 2-4 weeks 1
- If cough unresponsive to ICS, do NOT increase doses—consider alternative diagnoses 2
- If cough resolves, re-evaluate after stopping treatment as resolution may be spontaneous 2
Environmental Modifications
Essential Interventions
- Determine and address tobacco smoke exposure in all children with cough 1, 2
- Evaluate other environmental pollutants 2
- Assess and address parental expectations and specific concerns 1, 2
Common Pitfalls to Avoid
Clinical Errors
- Do not apply adult cough management approaches to pediatric patients 1, 2
- Do not prescribe OTC medications due to parental pressure despite lack of efficacy 2
- Do not empirically treat for asthma, GERD, or upper airway cough syndrome without clinical features consistent with these conditions 2
- Avoid medication errors from incorrect dosing, particularly in young children 5
- Do not use multiple cold/cough products containing the same ingredients 5
Management Failures
- Failure to re-evaluate children whose cough persists despite treatment 2
- Assuming all cough represents asthma and treating with bronchodilators without evidence of airflow obstruction 5
Key Educational Points for Parents
Expected Course
- Most acute coughs are self-limiting viral infections requiring only supportive care 2, 4
- Symptoms typically resolve within 2-4 weeks without intervention 1, 4
- OTC medications have little to no benefit in symptomatic control 2, 5, 6