What is the best course of action for a 14-month-old patient with a persistent cough?

Management of Persistent Cough in a 14-Month-Old

For a 14-month-old with persistent cough, first determine if the cough is wet/productive or dry, and if it has lasted more than 4 weeks—if wet and chronic (>4 weeks), start a 2-week course of amoxicillin or amoxicillin-clavulanate targeting protracted bacterial bronchitis. 1, 2

Initial Assessment: Define the Cough Duration and Character

Duration Classification

• Acute cough: Less than 3-4 weeks—most commonly post-viral and self-limited 2, 3
• Chronic cough: More than 4 weeks—requires systematic evaluation and treatment 1, 2, 3
• At 14 months of age, 90% of post-bronchiolitis coughs resolve by day 21 (mean 8-15 days), though 10% may persist beyond 20-25 days 2

Cough Character: Wet vs. Dry

• Wet/productive cough suggests protracted bacterial bronchitis (PBB), the most common cause of chronic cough in this age group 1, 2, 4
• Dry cough is most commonly post-viral from an upper respiratory infection 2

Management Algorithm Based on Duration and Character

If Cough Duration is LESS Than 4 Weeks

• Provide supportive care only: ensure adequate hydration, use antipyretics for comfort, and gentle nasal suctioning if needed 2
• Do NOT use over-the-counter cough and cold medications—they lack proven efficacy and carry serious toxicity risks, including 54 deaths from decongestants and 69 deaths from antihistamines in children under 6 years between 1969-2006 2
• Eliminate environmental tobacco smoke exposure immediately 1, 2, 4
• Monitor closely and reassess if symptoms worsen or fail to improve after 48 hours 2

If Cough Duration is MORE Than 4 Weeks (Chronic Cough)

For WET/PRODUCTIVE Cough Without Red Flags:

This is the most important pathway for this age group:

1. Start antibiotics immediately: Prescribe a 2-week course targeting Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis 1, 2, 4

   • First-line choice: Amoxicillin 45 mg/kg/day divided every 12 hours OR 40 mg/kg/day divided every 8 hours for severe infections 5
   • Alternative: Amoxicillin-clavulanate if local resistance patterns warrant 2

2. If cough resolves within 2 weeks: Diagnose as protracted bacterial bronchitis (PBB) 1

3. If wet cough persists after 2 weeks: Extend antibiotics for an additional 2 weeks 1

4. If wet cough persists after 4 weeks total of antibiotics: Proceed to further investigations including flexible bronchoscopy with quantitative cultures and consider chest CT 1, 3

For DRY Cough Without Red Flags:

• Adopt a "watch, wait, and review" approach initially, as this is most commonly post-viral 4
• Do NOT empirically treat for asthma—chronic cough alone does not indicate asthma in this age group, and most children with isolated chronic cough do not have asthma 1, 2, 4
• Review in 2-4 weeks to assess for resolution 4

Critical Red Flags Requiring Immediate Evaluation

Look for these "specific cough pointers" that indicate serious underlying disease 1, 2, 3, 4:

• Coughing with feeding (suggests aspiration or swallowing dysfunction)
• Digital clubbing (suggests chronic suppurative lung disease or bronchiectasis)
• Failure to thrive or poor weight gain
• Respiratory distress: respiratory rate >70 breaths/min, grunting, retractions, or cyanosis 2
• Oxygen saturation <92% 2
• Persistent high fever ≥39°C for 3+ consecutive days 2

Consider Pertussis If:

• Paroxysmal cough with post-tussive vomiting 1, 3
• Inspiratory "whoop" 1, 3
• Known contact with pertussis case 3
• Note: These can occur even in vaccinated children, with median cough duration of 29-39 days in vaccinated vs. 52-61 days in unvaccinated children 3

What NOT to Do (Common Pitfalls)

• Never use OTC cough medications in children under 2 years—major pharmaceutical companies voluntarily removed these from the market in 2007 due to lack of efficacy and serious safety concerns 2
• Never use topical decongestants in children under 1 year due to narrow therapeutic window and risk of cardiovascular/CNS toxicity 2
• Do not empirically treat for asthma, GERD, or upper airway cough syndrome unless specific clinical features support these diagnoses—this is a Grade 1A recommendation 1, 2, 4
• Do not perform chest physiotherapy—it is not beneficial and should not be done 2
• Do not obtain chest radiograph or spirometry unless cough persists to 4 weeks or red flags are present 2, 4

When to Refer or Escalate Care

• Any red flags present 2, 4
• Wet cough persisting after 4 weeks of appropriate antibiotics 1
• Symptoms deteriorating or not improving after 48 hours of supportive care 2
• Not feeding well or signs of dehydration 2