What is the recommended treatment for a pediatric patient coughing up green phlegm?

Management of Pediatric Patient Coughing Up Green Phlegm

A pediatric patient producing green (purulent) phlegm requires antibiotic therapy, as chronic productive cough with purulent sputum is not a typical symptom of asthma in children and warrants concern for bacterial infection. 1

Initial Assessment and Red Flags

When evaluating a child with productive green phlegm, immediately assess for:

• Duration of cough: If >4 weeks, this is chronic cough requiring systematic evaluation 2
• Specific cough pointers that indicate serious underlying disease 2:
  • Coughing with feeding (suggests aspiration)
  • Digital clubbing (suggests chronic suppurative lung disease)
  • Failure to thrive or growth retardation 1
  • Persistent fever despite initial treatment
• Respiratory compromise: Check oxygen saturation; levels <92% indicate severe disease 3

The younger the child, the more urgent the need to exclude underlying disease. 1

Diagnostic Approach

For Acute Presentation (<4 weeks)

• Obtain chest radiograph to evaluate for pneumonia or parapneumonic effusion 2, 3
• Perform blood cultures if fever is present or child appears systemically unwell 2
• Send sputum for bacterial culture when available 2

For Chronic Wet Cough (>4 weeks)

If the wet cough persists after 4 weeks of appropriate antibiotics, further investigations including flexible bronchoscopy with quantitative cultures and sensitivities with or without chest CT should be undertaken. 2

Antibiotic Treatment

First-Line Therapy for Protracted Bacterial Bronchitis (PBB)

Amoxicillin-clavulanate is the first-line antibiotic for children with chronic wet/productive cough, as the most common bacteria include Haemophilus influenzae, Streptococcus pneumoniae, and Moraxella catarrhalis 4:

• Standard course: 2 weeks minimum 4
• Extended therapy: Prolonged treatment (>2 weeks) is sometimes required for cough resolution 4
• Dosing: Follow standard pediatric weight-based dosing for amoxicillin-clavulanate

Alternative Antibiotic: Azithromycin

For children who cannot tolerate amoxicillin-clavulanate, azithromycin is an alternative 5:

• Community-acquired pneumonia: 10 mg/kg as single dose on Day 1, followed by 5 mg/kg once daily on Days 2-5 5
• Acute bacterial sinusitis: 10 mg/kg once daily for 3 days 5

When to Escalate Antibiotic Coverage

If high fever (≥38.5°C) persists for more than 3 days, beta-lactam antibiotics should be considered. 6

For confirmed pneumonia in children under 3 years, amoxicillin 80-100 mg/kg/day in three daily doses is recommended as first-line treatment. 6

Critical Conditions to Exclude

Parapneumonic Effusion/Empyema

All children with parapneumonic effusion or empyema must be admitted to hospital. 2, 3

If chest radiograph shows effusion:

• Ultrasound is mandatory to confirm presence and characteristics of pleural fluid 3
• Start IV antibiotics immediately covering Streptococcus pneumoniae 2, 3
• Consider drainage if effusion is enlarging or compromising respiratory function 3

Protracted Bacterial Bronchitis with Risk for Bronchiectasis

Recurrent PBB (>3 episodes/year) and H. influenzae infection are significant risk factors for developing bronchiectasis, requiring close follow-up and consideration of chest CT 4.

Other Serious Diagnoses

In children with chronic productive cough and specific pointers, investigate for 1:

• Cystic fibrosis (especially with failure to thrive)
• Aspirated foreign body (sudden onset, unilateral findings)
• Primary ciliary dyskinesia (chronic wet cough from infancy)
• Congenital anatomic abnormalities

Medications to AVOID

Over-the-counter cough and cold medicines should NOT be used in children, as they have not been shown to reduce cough severity or duration 6.

Antihistamines have minimal to no efficacy for cough relief and are associated with adverse events 6.

Do NOT use acid suppressive therapy (PPIs) solely for chronic cough unless clear gastrointestinal GERD symptoms are present (recurrent regurgitation, dystonic neck posturing in infants, heartburn/epigastric pain in older children) 2.

Follow-Up and Re-evaluation

Review the child if deteriorating or not improving after 48 hours of antibiotic therapy. 6

If wet cough persists despite 4 weeks of appropriate antibiotics, proceed to bronchoscopy and/or chest CT to assess for underlying disease 2.

Plan for 1-4 weeks of oral antibiotics after discharge, extending longer if residual disease persists. 3

Environmental Factors

Evaluate and address tobacco smoke exposure, as passive smoking is an important contributor to chronic cough in children 6, 1.