What is the appropriate treatment for a cough in pediatric patients?

Treatment for Cough in Children

Honey is the Only Recommended Treatment for Acute Cough in Children Over 1 Year

For acute cough in children over 1 year of age, honey is the first-line and only evidence-based treatment, providing superior symptom relief compared to no treatment, diphenhydramine, or placebo. 1, 2

Acute Cough Management (< 4 Weeks Duration)

Recommended Treatment:

• Honey (children > 1 year): Provides more relief than no treatment, antihistamines, or placebo 1, 2
• Never give honey to infants under 12 months due to risk of infant botulism 1, 2

Supportive Care Only:

• Antipyretics and analgesics for comfort 3
• Adequate hydration to thin secretions 3
• Gentle nasal suctioning for congestion 3
• Most viral coughs resolve within 1-3 weeks, though 10% persist beyond 20-25 days 3

Medications to AVOID Completely

Over-the-Counter Cough Medicines:

• Do not use OTC cough and cold medications in children - they lack efficacy, do not make cough less severe or resolve sooner, and are associated with significant morbidity and mortality 1, 2, 4
• Between 1969-2006, there were 54 deaths from decongestants and 69 deaths from antihistamines in children under 6 years 3

Specific Medications to Never Use:

• Codeine: Must be avoided due to potential respiratory distress and death; FDA restricts prescription opioid cough medicines to adults ≥18 years only 1
• Dextromethorphan: No different than placebo for nocturnal cough or sleep disturbance 1
• Antihistamines: Minimal to no efficacy and associated with adverse events 1
• Beta-agonists: Non-beneficial for acute viral cough with adverse events 3

When Antibiotics ARE Indicated for Acute Cough

Consider antibiotics only in these specific scenarios:

• High fever ≥38.5°C persisting for more than 3 days 1
• Clinically and radiologically confirmed pneumonia: Use amoxicillin 80-100 mg/kg/day in three divided doses (children under 3 years) 1
• Associated purulent acute otitis media 1
• Do NOT use antibiotics for common colds - they provide no benefit 1

Chronic Cough Management (≥ 4 Weeks Duration)

At 4 weeks, cough becomes "chronic" and requires systematic evaluation, not empirical treatment. 5, 1, 2

Mandatory Initial Investigations:

• Chest radiograph for all children with chronic cough 1, 2
• Spirometry (pre- and post-β2 agonist) if child ≥6 years old 1, 2
• Determine if cough is wet/productive versus dry 1, 2

Management Based on Cough Type:

Chronic Wet/Productive Cough (Protracted Bacterial Bronchitis):

• 2-week course of antibiotics targeting Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis 1, 2
• Use amoxicillin or amoxicillin-clavulanate as first-line 3, 2
• If cough persists after 2 weeks, extend treatment for additional 2 weeks 2

Chronic Dry/Non-Specific Cough with Asthma Risk Factors:

• Only if family history of asthma, atopy, or documented wheeze is present 1, 2
• Trial of low-dose inhaled corticosteroids (400 μg/day budesonide or beclomethasone equivalent) for 2-3 weeks 1, 2
• Mandatory re-evaluation at 2-4 weeks 1, 2
• If cough unresponsive to ICS, do NOT increase doses - discontinue and consider other diagnoses 1, 2
• Resolution may be spontaneous rather than treatment-related 1

Critical Red Flags Requiring Immediate Evaluation

Seek urgent evaluation if any of these are present:

• Coughing with feeding 1, 2
• Digital clubbing 1, 2
• Failure to thrive 1, 2
• Hemoptysis 3
• Respiratory rate >70 breaths/min (infants) or >50 breaths/min (older children) 3
• Difficulty breathing, grunting, or cyanosis 3
• Oxygen saturation <92% 3
• Persistent high fever ≥39°C for 3+ consecutive days 3

What NOT to Do - Common Pitfalls

Never use empirical treatment approaches without specific clinical features:

• Do not treat for asthma unless recurrent wheeze, dyspnea, or documented airway hyperresponsiveness is present 1, 2
• Do not treat for GERD unless GI symptoms present (recurrent regurgitation, dystonic neck posturing in infants, heartburn/epigastric pain in older children) 1, 2
• Do not treat for upper airway cough syndrome without specific features 1, 2
• Do not use adult cough management approaches in pediatric patients 1
• Do not use acid suppressive therapy solely for chronic cough 1

Environmental Modifications

Address these factors in all children with cough:

• Evaluate and eliminate tobacco smoke exposure 1, 2
• Assess other environmental pollutants 1
• Address parental expectations and concerns as part of consultation 1, 2

Follow-Up Timing

Re-evaluate if:

• Symptoms deteriorating or not improving after 48 hours 1, 3
• Cough persists beyond 2-4 weeks 1
• Child fails to respond to specific treatment 1
• Any new concerning symptoms develop 1, 3

Special Considerations for Infants Under 2 Years

• Never use topical decongestants in children under 1 year due to narrow therapeutic margin and risk of cardiovascular/CNS side effects 3
• Most acute viral bronchiolitis coughs resolve by day 21 (mean 8-15 days) 1
• If cough persists beyond 3-4 weeks in infants, transition to chronic cough evaluation 3