What are the recommendations for using anti-tussives (cough suppressants) in pediatric patients with viral respiratory infections?

Antitussives in Pediatric Viral Respiratory Infections

Antitussive medications should NOT be used in children with viral respiratory infections, as they lack efficacy and pose significant safety risks including morbidity and mortality. 1, 2

Clear Contraindications by Age and Medication Type

Children Under 2 Years

• All over-the-counter (OTC) cough and cold medicines are contraindicated due to lack of efficacy and risk of significant morbidity and mortality 2
• Codeine-containing medications must be avoided due to potential respiratory distress and serious adverse effects 2, 3
• Dextromethorphan is no more effective than placebo and is specifically advised against by the American Academy of Pediatrics 2, 4
• Antihistamines have minimal to no efficacy for cough relief and are associated with 69 reported fatalities in children under 6 years between 1969-2006 2, 4
• Decongestants caused 54 fatalities in children under 6 years, demonstrating narrow therapeutic windows and cardiovascular/CNS toxicity risk 2

All Pediatric Ages

• The American College of Chest Physicians recommends that cough suppressants and other OTC cough medicines should not be used in children, especially young children who may experience significant morbidity and mortality 1
• Systematic reviews demonstrate that OTC cough medications have little to no benefit in symptomatic control of acute cough in children 4, 5

Evidence-Based Alternatives

First-Line Treatment: Honey

• Honey is the ONLY recommended treatment for acute cough in children over 1 year of age 2, 4
• Honey provides more relief than diphenhydramine, placebo, or no treatment 2, 4
• Never give honey to infants under 12 months due to risk of infant botulism 4

Supportive Care Approach

• Watchful waiting and supportive care are appropriate for most cases, as acute viral coughs are typically self-limiting 2
• Most children with acute viral bronchiolitis are cough-free by day 21, with mean cough resolution of 8-15 days 1

Environmental and Preventive Measures

• Eliminate tobacco smoke exposure and assess for other environmental pollutants in all children with cough 2, 4
• Provide respiratory syncytial virus prophylaxis (if eligible), influenza and pneumococcal vaccinations 1
• Address parental expectations through education about the natural course of viral illness 2, 4

When to Consider Specific Interventions

Chronic Cough (>4 weeks) Post-Viral Bronchiolitis

• Manage according to CHEST pediatric chronic cough guidelines 1
• Do NOT use asthma medications unless other evidence of asthma is present (recurrent wheeze and/or dyspnea) 1
• Do NOT use inhaled osmotic agents 1

Wet/Productive Cough Lasting ≥2 Weeks

• Consider 2-week course of antibiotics (amoxicillin-clavulanate) targeting common respiratory bacteria (Streptococcus pneumoniae, Haemophilus influenzae, Moraxella catarrhalis) for protracted bacterial bronchitis 1, 6
• This represents bacterial infection, not viral, and requires different management 6

Suspected Asthma with Risk Factors

• Consider a short trial (2-4 weeks) of low-dose inhaled corticosteroids (400 μg/day beclomethasone or budesonide equivalent) 1, 4
• Always re-evaluate after 2-4 weeks - if cough persists, discontinue medication and consider other diagnoses 1, 4
• Do NOT increase doses if unresponsive 4

GERD Considerations

• Do NOT treat for GERD when there are no GI clinical features such as recurrent regurgitation, dystonic neck posturing (infants), or heartburn/epigastric pain (older children) 1, 4
• Acid suppressive therapy should not be used solely for chronic cough 1, 4

Critical Pitfalls to Avoid

• Do not prescribe antitussives due to parental pressure - parents who desire medication report similar improvement regardless of whether they receive medication, placebo, or no treatment 4
• Do not use adult cough management approaches in pediatric patients 4
• Do not assume all persistent coughs are viral - wet cough ≥2 weeks suggests bacterial involvement requiring antibiotics 6
• Always re-evaluate children whose cough persists beyond expected timeframes or who fail to respond to treatment 1, 4