Cough Suppressant Options for a Six-Year-Old
For a 6-year-old child with cough, honey (2.5-5 mL as needed) is the only recommended treatment, while all over-the-counter cough suppressants including dextromethorphan should be avoided due to lack of efficacy and potential harm. 1, 2
What TO Use: Honey
- Honey provides more relief for cough symptoms than no treatment, diphenhydramine, or placebo in children over 1 year of age 2
- Dosing: 2.5-5 mL as needed for symptom relief 2
- Critical safety warning: Never give honey to infants under 12 months due to botulism risk 2, 3
What NOT to Use: All OTC Cough Medicines
Dextromethorphan (DM)
- The American Academy of Pediatrics specifically advises against dextromethorphan for any type of cough in children 2
- Dextromethorphan is no different than placebo in reducing nocturnal cough or sleep disturbance 2
- While FDA labeling permits use in children 4-6 years at 2.5 mL every 12 hours, this contradicts pediatric guideline recommendations 4
- Systematic reviews demonstrate OTC cough medications have little or no benefit in symptomatic control of cough in children 2, 5
Other OTC Medications to Avoid
- Antihistamines have minimal to no efficacy for cough relief and are associated with adverse events 2
- Codeine-containing medications must be avoided due to potential serious side effects including respiratory distress 2, 3
- Guaifenesin and other expectorants lack evidence of efficacy in children 6, 5
- OTC cough and cold medications have been associated with significant morbidity and even mortality in children 1, 7
Supportive Care Measures
- Ensure adequate hydration to help thin secretions 1
- Use antipyretics (acetaminophen or ibuprofen) for fever and discomfort 1
- Address environmental tobacco smoke exposure 8, 2
- Gentle nasal suctioning for nasal congestion 1
When to Escalate Beyond Supportive Care
Acute Cough (< 4 weeks)
- Most acute viral coughs resolve within 1-3 weeks, though 10% persist beyond 25 days 1, 2
- Re-evaluate if cough persists beyond 2-4 weeks for emergence of specific etiological pointers 2
Chronic Cough (≥ 4 weeks)
- At 4 weeks duration, systematic evaluation is required using pediatric-specific algorithms 8, 1
- Mandatory investigations include chest radiograph and spirometry (pre- and post-β2 agonist) for children ≥6 years 8, 1
- Determine if cough is wet/productive versus dry, as this guides further management 8, 1
Red Flags Requiring Immediate Evaluation
- Coughing with feeding, digital clubbing, or failure to thrive 8, 1
- Respiratory rate >50 breaths/min, difficulty breathing, grunting, or cyanosis 1
- Oxygen saturation <92% 1
- Persistent high fever ≥39°C for 3+ consecutive days 1
Common Pitfalls to Avoid
- Do not prescribe OTC cough medications due to parental pressure despite lack of efficacy 2
- Do not use empirical treatment for asthma, GERD, or upper airway cough syndrome unless specific clinical features support these diagnoses 8, 2
- Do not diagnose asthma based on cough alone without demonstrating variable airflow obstruction and bronchodilator response 2, 9
- Do not use adult cough management approaches in pediatric patients 8, 2
Disease-Specific Considerations
If Asthma is Suspected (with risk factors)
- Consider a 2-3 week trial of low-dose inhaled corticosteroids (400 μg/day budesonide or beclomethasone equivalent) 2
- Reassess after 2-3 weeks—cough unresponsive to ICS should NOT be treated with increased doses 2
- Do not use β-agonists for acute viral cough as they are non-beneficial and have adverse events 2