What are the recommended treatments for a cough in a 5-year-old child?

Management of Cough in a 5-Year-Old Child

Do not use over-the-counter cough suppressants or cold medications in this child, as they provide no benefit and may cause serious harm. 1

First-Line Treatment Approach

For Acute Cough (Less Than 4 Weeks)

Honey is the recommended first-line treatment for acute cough in children over 1 year of age, as it provides more symptom relief than diphenhydramine, placebo, or no treatment. 2 The typical dose is 2.5-5 mL as needed, particularly before bedtime to reduce nighttime coughing. 2

Supportive care measures are essential:

• Ensure adequate hydration to help thin secretions 3
• Use acetaminophen or ibuprofen for fever and discomfort 3
• Address parental concerns and set realistic expectations about illness duration 1
• Identify and eliminate tobacco smoke exposure 1

Critical Safety Information

Never use codeine-containing medications due to risk of serious respiratory distress and death. 2, 4

Avoid all OTC cough suppressants (like dextromethorphan) and cold medications in children under 6 years, as they have not been shown to reduce cough severity or duration and carry significant risks of morbidity and mortality. 1 Between 1969-2006, there were 54 deaths from decongestants and 69 deaths from antihistamines in young children. 3

When Cough Becomes Chronic (Persists Beyond 4 Weeks)

Determine Cough Characteristics

If the cough is wet/productive:

• This likely represents protracted bacterial bronchitis (PBB) 2, 3
• Prescribe a 2-week course of amoxicillin or amoxicillin-clavulanate targeting Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis 2, 3
• If cough persists after 2 weeks of antibiotics, extend treatment for an additional 2 weeks 2
• When chronic wet cough resolves with antibiotics, this confirms the diagnosis of PBB 2

If the cough is dry/non-productive:

• Evaluate for post-infectious cough (most common after viral illness) 2
• Consider upper airway cough syndrome (post-nasal drip) 2
• Assess for asthma risk factors: family history of atopy, personal history of eczema, recurrent wheeze, exercise intolerance, or nocturnal symptoms 1, 2

Asthma Considerations - Important Caveats

Do not diagnose asthma based on cough alone. 1, 2, 3 The 2020 CHEST guidelines emphasize that chronic cough without wheeze is not associated with airway inflammation profiles suggestive of asthma and should not be treated with anti-asthma medications empirically. 1

Only consider a trial of inhaled corticosteroids if:

• The child has documented wheeze on examination 2
• There is exercise intolerance or nocturnal symptoms suggesting asthma 2
• There are clear asthma risk factors present 1

If you do trial inhaled corticosteroids, use beclomethasone 400 μg/day or equivalent budesonide for 2-4 weeks maximum. 1 Re-evaluate at 2-4 weeks and discontinue if no response. 1

Required Investigations for Chronic Cough

Obtain chest radiograph and spirometry (if child can perform it) as first-line investigations to assess for structural abnormalities and airway reactivity. 2

Look for specific "cough pointers" that indicate serious underlying disease:

• Coughing with feeding (suggests aspiration or swallowing dysfunction) 2, 3
• Digital clubbing (suggests chronic suppurative lung disease or bronchiectasis) 2, 3
• Failure to thrive or weight loss 2, 3
• Hemoptysis 2
• Focal findings on examination 2

If any of these pointers are present, further investigations beyond chest X-ray and spirometry are warranted, and referral to pediatric pulmonology should be considered. 2

Common Pitfalls to Avoid

Do not use empirical treatment approaches unless specific clinical findings support a particular diagnosis. 2, 3 If you do trial a medication, it must be for a defined, limited duration (2-4 weeks) to confirm or refute the diagnosis. 1, 2

Do not routinely perform additional tests like skin prick testing, Mantoux testing, bronchoscopy, or chest CT unless specifically indicated by clinical findings. 2

Do not assume atopy or positive allergy testing predicts response to asthma therapy in children with isolated cough. 1

When to Refer

Consider referral to pediatric pulmonology if:

• Cough fails to respond to appropriate initial management 2
• Specific cough pointers are present (hemoptysis, weight loss, persistent focal findings) 2
• Recurrent episodes despite appropriate treatment 2
• Suspected anatomical abnormality requiring specialized evaluation 2