Cough Suppressants in Children Under 2 Years Old
All over-the-counter cough and cold medicines, including cough suppressants, should NOT be used in children under 2 years of age due to lack of efficacy and risk of serious morbidity and mortality. 1
Contraindicated Medications
The following medications are specifically contraindicated in this age group:
- Codeine and codeine-containing medications must be avoided due to potential respiratory distress, respiratory drive suppression, and serious adverse effects including death 1, 2
- Dextromethorphan is no more effective than placebo and has been specifically advised against by the American Academy of Pediatrics 1
- Antihistamines have minimal to no efficacy for cough relief and are associated with 69 reported fatalities in children under 6 years between 1969-2006 1
- Decongestants caused 54 fatalities in children under 6 years, demonstrating their narrow therapeutic window and cardiovascular/CNS toxicity risk 1
Recommended Treatment Approach
For children under 1 year: Supportive care and watchful waiting are the only appropriate interventions, as acute coughs are typically self-limiting viral infections 1
For children 1-2 years old: Honey is the only treatment recommended by the American Academy of Pediatrics for acute cough, providing more relief than diphenhydramine, placebo, or no treatment 1
Essential Supportive Care Measures
- Eliminate tobacco smoke exposure and other environmental pollutants, which should be assessed in all children with cough 1
- Address parental expectations through education about the natural course of viral illness 1
- Provide reassurance that most acute coughs resolve spontaneously without medication 3
When to Consider Specific Interventions
If Asthma is Suspected:
- Consider a 2-4 week trial of low-dose inhaled corticosteroids only if there are clear asthma features (wheeze, exercise intolerance, nocturnal symptoms) 1
- Always re-evaluate after the trial period 1
- Beta-agonists like salbutamol should NOT be used in children with acute cough and no evidence of airflow obstruction 1
If GERD is Suspected:
- GERD treatment should only be considered if gastrointestinal symptoms are present (recurrent regurgitation, dystonic neck posturing in infants), not for cough alone 4, 1
- Acid suppressive therapy should not be used solely for chronic cough 4
Critical Pitfalls to Avoid
- Do not assume that cough suppressants are safe simply because they are available over-the-counter; emergency departments treated over 1,500 children under age 2 for adverse events related to OTC cough and cold medications in just a 2-year period 5
- Do not use empirical treatment approaches without specific clinical findings supporting a particular diagnosis 6
- Do not treat chronic cough without wheeze as asthma; chronic cough without wheeze is not associated with airway inflammation profiles suggestive of asthma 6