PRN Medication for Cough and Shortness of Breath in a 7-Year-Old Male
For a 7-year-old male with cough and shortness of breath, prescribe albuterol (short-acting beta-agonist) as the PRN medication if asthma or reactive airway disease is suspected, using 2 puffs via metered-dose inhaler with spacer or nebulized solution (2.5 mg) as needed for symptom relief. 1
Clinical Decision Algorithm
Step 1: Determine if Symptoms Suggest Asthma or Reactive Airway Disease
- If the child has wheezing, shortness of breath, or cough that worsens with activity or at night, this strongly suggests asthma or reactive airway disease requiring bronchodilator therapy 1
- Look for specific indicators: nocturnal cough, exercise-induced symptoms, or ability to perform usual activities 1
- Albuterol is NOT recommended for cough alone without evidence of bronchospasm 1
Step 2: Prescribe Appropriate Albuterol Formulation
For PRN use in a 7-year-old:
Metered-dose inhaler (MDI) with spacer: 2 puffs (90 mcg/puff = 180 mcg total dose) every 4-6 hours as needed 1
Nebulized albuterol solution: 2.5 mg (0.5 mL of 0.5% solution diluted in 2-3 mL normal saline) every 4-6 hours as needed 2
- Safety and effectiveness established in children 2 years and older 2
Step 3: Establish Action Plan Zones
Green Zone (Doing Well):
- No cough, wheeze, or shortness of breath
- Can do usual activities
- Use albuterol only as needed for symptoms 1
Yellow Zone (Getting Worse):
- Cough, wheeze, shortness of breath, or nighttime awakening
- Can do some but not all usual activities
- Continue quick-relief medicine every 4 hours as needed 1
- Call provider if not improving in 1-2 days 1
Red Zone (Medical Alert):
- Very short of breath
- Quick-relief medicines have not helped
- Cannot do usual activities
- Call 911 if trouble walking/talking due to shortness of breath 1
Critical Caveats and Pitfalls
What NOT to Prescribe
Avoid over-the-counter cough suppressants:
- Cough suppressants and OTC cough medicines should NOT be used in children, as they may cause significant morbidity and mortality, especially in young children 1
- Codeine-containing medications should be avoided due to potential for serious side effects including respiratory distress 1
- Dextromethorphan and antihistamine-containing OTC preparations have limited efficacy and are associated with adverse events in children 1
Albuterol is NOT appropriate if:
- Cough is due to upper respiratory infection (URI) without bronchospasm 1
- Chronic cough without wheezing or asthma features 1
Proper Inhaler Technique is Essential
- Ensure proper spacer use and inhalation technique - poor technique dramatically reduces efficacy 1
- For children unable to coordinate MDI use, nebulizer is preferred 1
- Each puff should be given sequentially with proper inhalation 1
When to Escalate Care
If symptoms require albuterol more than twice weekly (excluding exercise-induced symptoms), the child needs controller medication (inhaled corticosteroid) and should be evaluated for persistent asthma 1
Re-evaluate within 2 weeks if starting any new medication to assess response 1
Alternative Considerations
If Asthma is Confirmed with Chronic Symptoms
- Consider trial of inhaled corticosteroid (beclomethasone 400 μg/day or equivalent budesonide) for 2-4 weeks if risk factors for asthma are present 1
- However, most children with nonspecific cough do NOT have asthma 1
- Always re-evaluate in 2-4 weeks and discontinue if no improvement 1
If Post-Prematurity Respiratory Disease
- For children with history of prematurity who have recurrent respiratory symptoms (cough or wheeze), a trial of short-acting inhaled bronchodilator with monitoring is appropriate 1
- Do NOT routinely prescribe for those without recurrent symptoms 1