What is the recommended treatment for a pediatric patient presenting with a cough?

Pediatric Cough Management

Over-the-counter cough syrups should NOT be used in children, as they provide no benefit and may cause significant harm including death, particularly in young children. 1, 2

What NOT to Use

• Cough suppressants (including dextromethorphan) and OTC cough medicines are contraindicated in pediatric patients, especially those under 6 years of age, due to lack of efficacy and risk of serious morbidity and mortality 1, 2, 3

• Antihistamines (including diphenhydramine) have minimal to no efficacy for cough relief in children and are associated with adverse events 1, 2

• Codeine-containing medications must be avoided due to potential serious side effects including respiratory distress 2

• Decongestants should not be used in children under 1 year due to narrow therapeutic margin and risk of cardiovascular and CNS toxicity 3

Between 1969-2006, there were 54 deaths associated with decongestants and 69 deaths associated with antihistamines in children under 6 years, leading to voluntary market withdrawal of these products for children under 2 years in 2007 3

Recommended Treatment Approach

For Acute Cough (< 4 weeks)

Honey is the first-line treatment for children over 1 year old, providing more relief than diphenhydramine, placebo, or no treatment 2

• Never give honey to infants under 12 months due to risk of infant botulism 2

• Supportive care only for most viral coughs, which typically resolve within 1-3 weeks (though 10% persist beyond 20-25 days) 2, 3

• Acetaminophen or ibuprofen may be used for fever and discomfort to keep the child comfortable 3

For Chronic Cough (≥ 4 weeks)

At 4 weeks duration, systematic evaluation is mandatory rather than continued symptomatic treatment 1, 2

Mandatory initial investigations include: 2, 4

• Chest radiograph to identify structural abnormalities, pneumonia, or foreign body
• Spirometry (pre- and post-β2 agonist) if child is ≥6 years old and able to perform reliably
• Assessment of whether cough is wet/productive versus dry, as this guides the diagnostic algorithm

For chronic wet/productive cough without specific red flags: 2, 4

• Prescribe a 2-week course of antibiotics targeting Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis (amoxicillin or amoxicillin-clavulanate as first-line)
• This likely represents protracted bacterial bronchitis
• If cough persists after 2 weeks, extend antibiotics for an additional 2 weeks

For chronic dry cough with asthma risk factors: 1, 2

• Consider a short trial (2-4 weeks) of low-dose inhaled corticosteroids (beclomethasone 400 μg/day or budesonide equivalent)
• Reassess after 2-3 weeks - if no response, discontinue medication and consider other diagnoses
• Do not increase ICS doses for unresponsive cough
• Most children with isolated chronic cough do NOT have asthma

Red Flags Requiring Immediate Evaluation

Seek urgent medical attention if the child has: 2, 3

• Coughing with feeding
• Digital clubbing
• Failure to thrive or weight loss
• Hemoptysis
• Respiratory rate >70 breaths/min (infants) or >50 breaths/min (older children)
• Difficulty breathing, grunting, or cyanosis
• Oxygen saturation <92%
• Not feeding well or signs of dehydration
• Persistent high fever ≥39°C for 3+ consecutive days

Critical Pitfalls to Avoid

• Do NOT use adult cough management approaches in pediatric patients 2

• Do NOT prescribe empirical treatment for asthma, GERD, or upper airway cough syndrome unless specific clinical features support these diagnoses 1, 2, 4

• Do NOT diagnose asthma based on cough alone - chronic cough without wheeze is not associated with airway inflammation profiles suggestive of asthma 4

• Do NOT continue ineffective medications - if cough does not resolve within the expected time frame (2-4 weeks), withdraw the medication and reconsider the diagnosis 1, 2

• Do NOT use chest physiotherapy in children with pneumonia or respiratory infections 3

Environmental and Parental Considerations

• Identify and eliminate tobacco smoke exposure in all children with cough 1, 2

• Address parental expectations and concerns as part of the clinical consultation, as parental perception often influences management 1, 2

• Ensure adequate hydration to help thin secretions 3

Follow-Up Recommendations

• Review the child if deteriorating or not improving after 48 hours 2, 3

• Re-evaluate at 2-4 weeks if any medication trial was initiated 1, 2

• Transition to chronic cough evaluation if cough persists beyond 4 weeks using pediatric-specific algorithms 1, 2