What is the appropriate management for a 1-year-old presenting with a cough?

Management of Cough in a 1-Year-Old Child

For a 1-year-old presenting with cough, provide supportive care only—do NOT use over-the-counter cough and cold medications, as they lack proven efficacy and carry serious safety risks including reported fatalities in this age group. 1

Immediate Safety Considerations

• Avoid all OTC cough and cold medications in children under 2 years due to lack of efficacy and potential for serious toxicity, including 43 deaths in infants under 1 year associated with decongestants between 1969-2006 1
• Do not use topical decongestants in children under 1 year due to narrow therapeutic margin and risk of cardiovascular/CNS side effects 1
• Major pharmaceutical companies voluntarily removed these products from the market for children under 2 years in 2007 1

Determine Cough Duration and Characteristics

If Acute Cough (Less Than 4 Weeks)

Most likely cause: Post-viral upper respiratory infection, which typically resolves within 1-3 weeks (though 10% persist beyond 20-25 days) 1, 2

Supportive care measures:

• Ensure adequate hydration to thin secretions 1, 2
• Use acetaminophen for fever and discomfort (weight-based dosing) to reduce coughing episodes 1
• Gentle nasal suctioning may help improve breathing 1
• Supported sitting position may help expand lungs and improve respiratory symptoms 1
• Address environmental tobacco smoke exposure 1, 2

Red flags requiring immediate medical attention:

• Respiratory rate >70 breaths/min 1
• Difficulty breathing, grunting, or cyanosis 1
• Oxygen saturation <92% if measured 1
• Not feeding well or signs of dehydration 1
• Persistent high fever or worsening symptoms 1

Follow-up timing: Review by healthcare provider if symptoms deteriorate or do not improve after 48 hours 1

If Chronic Cough (4 Weeks or Longer)

At 4 weeks, systematic evaluation is required using pediatric-specific algorithms, as adult causes of chronic cough do not apply to children 3

Key distinction: Determine if the cough is wet/productive versus dry, as this is the most important divergence point in pediatric cough evaluation 3, 4

Mandatory initial investigations:

• Chest radiograph 3
• Spirometry is recommended when age-appropriate (typically >6 years), but a 1-year-old cannot reliably perform this test 3

For wet/productive chronic cough:

• Consider protracted bacterial bronchitis and treat with 2-week course of antibiotics targeting Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis 1, 2

For dry chronic cough:

• Evaluate for specific cough pointers: coughing with feeding, digital clubbing, failure to thrive 1
• Do NOT empirically treat for asthma unless other features consistent with asthma are present (recurrent wheeze, dyspnea responsive to bronchodilators) 3, 2

Critical Pitfalls to Avoid

• Never use empirical treatment for upper airway cough syndrome, gastroesophageal reflux disease, or asthma unless specific features of these conditions are present 3
• Do not routinely perform additional tests (skin prick test, Mantoux, bronchoscopy, chest CT) unless individualized based on specific clinical findings 3
• Do not perform chest physiotherapy, as it is not beneficial in children with respiratory infections 1
• Always seek history of choking episode to rule out foreign body aspiration, even if unwitnessed, as this can cause chronic respiratory damage 3

Special Considerations for This Age Group

• Consider pertussis if there is post-tussive vomiting, paroxysmal cough, or inspiratory whoop 3
• Evaluate for foreign body aspiration even with normal chest radiograph, as this does not exclude the diagnosis 3
• If empirical trial is warranted based on specific clinical features, limit to defined duration (2-4 weeks) to confirm or refute diagnosis 3