Management of 9-Month-Old with 2-Week Cough, Green Rhinorrhea, and Raspy Voice
This 9-month-old infant requires supportive care only at this time—no antibiotics, no cough medications, and no imaging unless red flags develop. 1
Initial Assessment Priorities
Immediately evaluate for signs requiring urgent intervention:
- Respiratory rate: Concerning if >70 breaths/min 1, 2
- Respiratory distress signs: Retractions, grunting, nasal flaring, or cyanosis 1, 2
- Oxygen saturation: Requires immediate attention if <92% 1, 2
- Feeding ability: Inability to feed or signs of dehydration warrant urgent evaluation 1, 2
- Fever pattern: Persistent high fever ≥39°C for 3+ consecutive days is a red flag 1
Why Supportive Care Is the Correct Approach
The American Academy of Pediatrics explicitly recommends against OTC cough and cold medications in children under 2 years due to lack of efficacy and serious safety concerns, including 43 deaths in infants under 1 year from decongestants alone between 1969-2006. 1
The green rhinorrhea does not indicate bacterial infection requiring antibiotics—color of nasal discharge does not reliably distinguish viral from bacterial infection in young children. 1 This 2-week duration represents a typical viral upper respiratory infection, which commonly causes the raspy voice (likely laryngeal inflammation from the viral process). 3, 4
Specific Supportive Measures
Provide the following interventions:
- Hydration: Continue breastfeeding or formula feeding to maintain hydration and thin secretions 1, 2
- Nasal congestion relief: Saline nasal drops followed by gentle suctioning 1, 2
- Positioning: Elevate head of bed during sleep for comfort 5, 2
- Environmental control: Eliminate tobacco smoke exposure and other irritants 1, 2
- Fever management: Antipyretics (acetaminophen or ibuprofen if >6 months) for comfort only 1
Critical Timing: When This Becomes Chronic Cough
At 4 weeks duration (not before), this transitions from acute to chronic cough requiring different management. 6, 1 If the wet cough persists to 4 weeks, then:
- Obtain chest radiograph 1, 5
- Initiate 2-week course of antibiotics targeting Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis (amoxicillin is first-line) 1, 5, 3
- This addresses protracted bacterial bronchitis, the most common cause of chronic wet cough in this age group 5
Red Flags Requiring Immediate Return
Instruct parents to seek immediate medical attention if:
- Respiratory distress develops: Retractions, grunting, nasal flaring, cyanosis 1, 2
- Respiratory rate exceeds 70 breaths/min 1, 2
- Oxygen saturation drops below 92% (if measured at home) 1, 2
- Fever develops or persists: Especially ≥39°C 1, 2
- Feeding difficulties or dehydration signs emerge 1, 2
- Cough pattern changes: Paroxysmal episodes with post-tussive vomiting or inspiratory "whoop" (concerning for pertussis in incompletely vaccinated infants) 2
What NOT to Do
Avoid these common pitfalls:
- No antibiotics at 2 weeks: The CHEST guidelines define chronic cough requiring antibiotics as >4 weeks duration, not 2 weeks 6, 1
- No bronchodilators or corticosteroids: These have no proven benefit in viral bronchiolitis or upper respiratory infections 1, 5, 3
- No chest radiograph now: Routine imaging in uncomplicated upper respiratory infections shows abnormalities in up to 97% of infants with recent colds, making them non-specific and unhelpful 1
- No topical decongestants: Narrow margin between therapeutic and toxic doses in infants under 1 year increases risk for cardiovascular and CNS side effects 1
- No GERD treatment: Treatment for GERD should not be used when there are no GI clinical features such as recurrent regurgitation or dystonic neck posturing 6
Follow-Up Plan
Schedule reassessment if symptoms are deteriorating or not improving after 48 hours. 1 Most viral respiratory infections resolve within 7-10 days, though 10% may persist beyond 20-25 days. 1 The raspy voice should improve as the laryngeal inflammation resolves with the viral illness. 3, 4