Management of Acute Cough in a 13-Year-Old
This is a classic viral upper respiratory infection that requires supportive care only—antibiotics are explicitly contraindicated and provide no benefit. 1, 2
Initial Assessment
The clinical presentation—cough, low-grade fever, fatigue, and body aches without sore throat, headache, or congestion—is consistent with acute viral bronchitis or early postinfectious cough. 2, 3 This is a self-limited condition that typically resolves within 2-3 weeks. 3
Key features that confirm this is NOT bacterial:
- No high fever (low-grade only) 2
- No respiratory distress or abnormal vital signs 2
- No concerning physical exam findings (assuming clear lungs) 1
- Duration less than 3 weeks (still in acute phase) 4, 1
Recommended Treatment Algorithm
First-Line: Supportive Care
Start with acetaminophen for fever and body aches, dosed appropriately for age and weight. 2, 5 This addresses the systemic symptoms (fever, fatigue, body aches) directly.
Add honey for cough suppression (1-2 teaspoons as needed), which has moderate evidence for reducing cough through central modulation of the cough reflex. 1, 2 This is safe and effective in adolescents.
Ensure adequate hydration and rest. 1, 2
If Cough Persists Beyond 1-2 Weeks
If the cough continues to significantly affect quality of life after 1-2 weeks, consider inhaled ipratropium bromide 2-3 puffs four times daily, which has the strongest evidence for attenuating postinfectious cough. 1, 2 This would transition the diagnosis from acute cough to postinfectious cough (defined as 3-8 weeks duration). 1
What NOT to Do
Do NOT prescribe antibiotics. The American College of Chest Physicians explicitly states that antibiotics have no role in viral or postinfectious cough, as the cause is not bacterial infection. 4, 1, 6 Antibiotics provide no benefit, contribute to antimicrobial resistance, and cause unnecessary adverse effects. 1, 3
Do NOT prescribe oral corticosteroids at this stage. Prednisone is reserved only for severe paroxysms of postinfectious cough that significantly impair quality of life, and only after other common causes have been ruled out. 4, 1
Red Flags Requiring Immediate Re-evaluation
Instruct the patient/family to return immediately if: 2, 6
- Breathing difficulty or respiratory distress develops 2
- Hemoptysis occurs 6
- High fever (≥38°C) develops or persists 6
- Symptoms worsen rather than gradually improve 1
Follow-Up Considerations
If cough persists beyond 3 weeks, this becomes postinfectious cough and warrants reassessment. 1 At that point, consider ipratropium bromide as described above.
If cough extends beyond 8 weeks, reclassify as chronic cough and systematically evaluate for upper airway cough syndrome (UACS), asthma, and gastroesophageal reflux disease (GERD). 4, 1, 7
Common Pitfalls to Avoid
- Colored sputum does NOT indicate bacterial infection—viral infections commonly produce purulent-appearing sputum. 4, 6
- Do not reflexively prescribe antibiotics for low-grade fever with cough—most cases remain viral. 6, 3
- Consider pertussis if cough develops paroxysmal quality, post-tussive vomiting, or inspiratory whooping, especially if cough persists beyond 2 weeks. 4, 6
Expected Timeline
Most acute viral coughs resolve within 10-14 days, though some may persist for 2-3 weeks. 1, 3 Emphasize this natural course with the patient and family to set appropriate expectations and reduce unnecessary follow-up or antibiotic requests. 3