What is the appropriate treatment for a child with a nocturnal dry cough that causes sleep disturbances and occasional vomiting?

Management of Nocturnal Dry Cough in Children

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

Immediate Management: Supportive Care Only

The appropriate treatment for a child with isolated nocturnal dry cough is supportive care measures only—no medications are indicated at this stage. 1, 2

Specific Supportive Measures to Implement

• Maintain adequate hydration through continued fluid intake to help thin secretions 2
• Elevate the head of the bed during sleep to improve comfort and reduce coughing episodes 2
• Use saline nasal drops if any nasal congestion is contributing to post-nasal drip 2
• Minimize environmental irritants, particularly tobacco smoke exposure and other pollutants 3, 2
• Address parental concerns and set realistic expectations about illness duration 4

What NOT to Prescribe

• Do not prescribe over-the-counter cough and cold medications in children under 6 years due to lack of efficacy and risk of serious adverse events, including multiple reported fatalities 1
• Do not prescribe codeine-containing medications due to potential for serious side effects including respiratory distress 4, 2
• Do not prescribe dextromethorphan or other cough suppressants, as they have not been shown to be effective in children 2, 5
• Do not prescribe antibiotics at this initial presentation—a dry cough in an otherwise well child is consistent with viral infection and does not warrant antibiotics 2
• Do not prescribe asthma medications unless other features of asthma are present, such as recurrent wheeze, exercise intolerance, or documented wheeze on examination 4, 2

Understanding the Clinical Context

Expected Natural Course

Most viral-associated coughs resolve within 7-10 days, with 90% of children cough-free by day 21. 2 This represents either post-viral cough or acute bronchitis, both of which are self-limited. 2

Why Nocturnal Cough Alone Is Unreliable

The major problem with using nocturnal cough as a diagnostic criterion is the unreliability and inconsistency of its reporting when compared to objective measurements. 3 Studies show poor agreement between subjective and objective assessment of nocturnal cough (Cohen's kappa of 0.3). 3 Parents often perceive nocturnal cough as more troublesome than daytime cough, even when objective measurements show otherwise. 3

Nocturnal Cough Does Not Equal Asthma

Only one-third of children with isolated nocturnal cough (without wheezing, shortness of breath, or chest tightness) have an asthma-like illness. 3 Chronic cough without wheeze is not associated with airway inflammation profiles suggestive of asthma. 4 Do not diagnose asthma based on cough alone. 4

When to Reassess or Escalate Care

Return Immediately If:

• Respiratory distress develops (increased work of breathing, grunting, retractions) 2
• Fever develops 2
• Oxygen saturation drops below 92% 2
• Cough becomes paroxysmal with post-tussive vomiting or inspiratory "whoop" (consider pertussis) 2
• Inability to feed or signs of dehydration develop 2

Scheduled Follow-Up at 4 Weeks If Cough Persists

If the dry cough continues beyond 4 weeks, this transitions from acute to chronic cough and requires systematic evaluation. 3, 2

At the 4-week mark:

• Obtain chest radiograph and spirometry as first-line investigations 4
• Evaluate for specific cough pointers including coughing with feeding, digital clubbing, failure to thrive, hemoptysis, or recurrent pneumonia 3
• If the cough has changed from dry to wet/productive, initiate a 2-week course of antibiotics targeting common respiratory bacteria (Streptococcus pneumoniae, Haemophilus influenzae, Moraxella catarrhalis) for presumed protracted bacterial bronchitis 3, 2
• If the cough remains dry with no other symptoms, this is termed "nonspecific cough"—continue watchful waiting as most resolve spontaneously 2

Common Pitfalls to Avoid

• Over-diagnosing asthma in children with isolated dry cough 2
• Prescribing empirical asthma medications without evidence of airway obstruction 2
• Using antihistamines for acute cough, as they are non-beneficial 1
• Using β-agonists for acute viral cough, as they are non-beneficial and have adverse events 1
• Treating empirically for GERD when there are no gastrointestinal symptoms such as recurrent regurgitation, heartburn, or epigastric pain 3

Parent Education Points

• Explain that this is likely a self-limited viral illness that will resolve in 7-10 days 2
• Provide clear instructions on warning signs requiring immediate return 2
• Emphasize hand hygiene and avoiding contact with sick individuals to prevent spread 2
• Reassure that no medication is needed or beneficial at this stage—supportive care is the appropriate evidence-based approach 1, 2