What are the appropriate management and treatment options for a child presenting with a cough?

Management of Cough in Children

For children with acute cough (less than 4 weeks), honey is the first-line treatment for children over 1 year old, while over-the-counter cough and cold medications should never be used as they provide no benefit and risk serious harm. 1, 2

Acute Cough Management (Duration < 4 Weeks)

What TO Use

• Honey (for children > 1 year) provides more relief than no treatment, diphenhydramine, or placebo and should be the primary treatment 1, 2
• Acetaminophen or ibuprofen for fever and discomfort to keep the child comfortable 1, 3
• Adequate hydration to thin secretions 3, 2
• Gentle nasal suctioning if nasal congestion is present 3, 2

What NOT to Use

• Over-the-counter cough and cold medications are contraindicated in children under 6 years due to lack of efficacy and risk of serious toxicity, including 54 deaths from decongestants and 69 deaths from antihistamines in children under 6 years between 1969-2006 1, 4
• Codeine-containing medications must be avoided due to potential for respiratory distress 1, 2
• Beta-agonists are non-beneficial for acute viral cough and cause adverse events 4
• Antihistamines provide no benefit for acute cough 4

Expected Course and When to Reassess

• Most acute viral coughs resolve within 1-3 weeks, though 10% persist beyond 20-25 days 4
• If cough persists beyond 4 weeks, it transitions to "chronic cough" and requires systematic evaluation with chest radiograph and spirometry (if age ≥6 years) 1, 3, 2

Chronic Cough Management (Duration ≥ 4 Weeks)

Initial Evaluation: Wet vs. Dry Cough Classification

The management algorithm fundamentally depends on whether the cough is wet/productive versus dry 1, 3

For Chronic WET/Productive Cough (Without Specific Cough Pointers)

This likely represents protracted bacterial bronchitis (PBB) and should be treated with antibiotics. 1

Treatment Protocol:

1. Prescribe 2 weeks of antibiotics targeting common respiratory bacteria (Streptococcus pneumoniae, Haemophilus influenzae, Moraxella catarrhalis) based on local antibiotic sensitivities 1

   • First-line choice: Amoxicillin or amoxicillin-clavulanate 3, 5
   • Alternative: Azithromycin (10 mg/kg/day for 3 days or 30 mg/kg single dose) 6

2. If cough resolves within 2 weeks of antibiotics, diagnose PBB 1

3. If wet cough persists after 2 weeks of appropriate antibiotics, prescribe an additional 2 weeks of antibiotics 1

4. If wet cough persists after 4 weeks total of appropriate antibiotics, perform further investigations including flexible bronchoscopy with quantitative cultures and/or chest CT 1

For Chronic DRY Cough

Do not diagnose asthma based on cough alone—chronic cough without wheeze is not associated with airway inflammation profiles suggestive of asthma. 3, 4

When to Consider Asthma:

Only consider a trial of inhaled corticosteroids if the child has: 3

• Documented wheeze on examination, OR
• Exercise intolerance or nocturnal symptoms suggesting asthma, OR
• Clear asthma risk factors present

If trialing inhaled corticosteroids: 3

• Use beclomethasone 400 μg/day or equivalent budesonide
• Maximum duration: 2-4 weeks
• Re-evaluate at 2-4 weeks and discontinue if no response

Other Considerations for Dry Cough:

• Upper airway cough syndrome (post-nasal drip) 3
• Post-infectious cough following recent respiratory infection 3

Critical Cough Pointers Requiring Immediate Investigation

If ANY of these "red flags" are present, do not treat empirically—proceed directly to investigations: 1

Systemic Pointers:

• Digital clubbing 1
• Failure to thrive 1
• Cardiac abnormalities 1
• Neurodevelopmental abnormality 1
• Immunodeficiency 1

Pulmonary Pointers:

• Coughing with feeding 1
• Hemoptysis 1
• Abnormal cough characteristics (brassy, paroxysmal with posttussive vomiting, staccato, cough from birth) 1
• Recurrent pneumonia 1
• Hypoxia/cyanosis 1
• Auscultatory findings (stridor, wheeze, crackles) 1
• Chest radiograph abnormalities 1

For children with these pointers, perform flexible bronchoscopy and/or chest CT, assessment for aspiration, and/or evaluation of immunologic competency 1

GERD and Cough

Treatment for GERD should NOT be used when there are no GI clinical features of GERD. 1

• GERD is not a common cause of isolated chronic cough in children without GI symptoms 1
• Only treat for GERD if the child has recurrent regurgitation, dystonic neck posturing (infants), or heartburn/epigastric pain (older children) 1
• If GERD symptoms are present, treat according to evidence-based GERD-specific guidelines 1

Common Pitfalls to Avoid

• Never use empirical treatment approaches unless specific clinical findings support a particular diagnosis 1, 3
• Do not assume atopy or positive allergy testing predicts response to asthma therapy in children with isolated cough 3
• Any empirical trial should be limited to 2-4 weeks maximum to confirm or refute the diagnosis 1, 3
• Avoid routine performance of additional tests (skin prick test, Mantoux, bronchoscopy, chest CT) unless specifically indicated by clinical findings 3

Environmental Factors

• Identify and eliminate environmental tobacco smoke exposure, which exacerbates respiratory symptoms 1, 3
• Address other environmental pollutants 3

Parent Education and Expectations

• Address parents' expectations and concerns directly 3
• Educate about expected illness duration for acute cough (1-3 weeks typically) 4
• Explain risks of over-the-counter medications 2

Warning Signs Requiring Immediate Medical Attention:

• Respiratory distress or difficulty breathing 4, 2
• Oxygen saturation <92% 4, 2
• Poor feeding or signs of dehydration 4, 2
• Persistent high fever ≥39°C for 3+ consecutive days 4