What are the recommended treatments for cough in children, considering age and underlying medical conditions such as asthma?

Cough Treatment in Children

Primary Recommendation

For children over 1 year of age with acute cough, honey is the only recommended treatment, providing superior relief compared to no treatment, diphenhydramine, or placebo. 1

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Acute Cough Management (< 4 weeks duration)

What TO Use

• Honey (children > 1 year): First-line treatment that provides more symptom relief than over-the-counter medications or placebo 1
• Supportive care only: Most acute coughs are self-limiting viral infections requiring no medication 1
• Acetaminophen or ibuprofen: May be used for fever and discomfort, though not directly for cough suppression 2

What NOT to Use

• Over-the-counter cough and cold medicines: Should never be used in children as they have not been shown to reduce cough severity or duration, and are associated with significant morbidity and mortality 1, 3
• Dextromethorphan: Specifically advised against by the American Academy of Pediatrics for any type of cough in children, as it is no different than placebo 1
• Codeine-containing medications: Must be avoided due to potential serious side effects including respiratory distress and death; FDA restricts prescription opioid cough medicines to adults ≥18 years only 1
• Antihistamines: Have minimal to no efficacy for cough relief and are associated with adverse events 1

Critical Safety Warning

• Never give honey to infants under 12 months due to risk of infant botulism 1

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Chronic Cough Management (≥ 4 weeks duration)

Mandatory Initial Evaluation

All children with cough lasting ≥4 weeks require systematic evaluation using pediatric-specific protocols, not empirical treatment. 4, 1

• Chest radiograph: Mandatory for all children with chronic cough 4, 1
• Spirometry (pre- and post-β2 agonist): Required when age-appropriate (typically ≥6 years) 4, 1
• Assess cough characteristics: Determine if cough is wet/productive versus dry, as this fundamentally guides management 1, 2
• Evaluate for specific cough pointers: Look for coughing with feeding, digital clubbing, failure to thrive, hemoptysis 1

Treatment Based on Cough Type

Wet/Productive Cough (≥4 weeks)

• Protracted bacterial bronchitis is the likely diagnosis 1
• Prescribe 2-week course of antibiotics targeting Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis 1
• Amoxicillin or amoxicillin-clavulanate are first-line choices for children under 5 years 1, 3
• If cough persists after 2 weeks: Prescribe an additional 2 weeks of antibiotics 2
• If cough resolves with antibiotics: Diagnosis of protracted bacterial bronchitis is confirmed 2

Dry/Non-productive Cough (≥4 weeks)

• Do NOT empirically treat for asthma unless other features consistent with asthma are present (recurrent wheeze, dyspnea, exercise intolerance, nocturnal symptoms) 4, 1
• Consider asthma only if: Child has documented wheeze on examination, exercise intolerance, nocturnal symptoms, or clear asthma risk factors 2
• If asthma is suspected with risk factors: Trial of low-dose inhaled corticosteroids (400 μg/day budesonide or beclomethasone equivalent) for 2-3 weeks maximum 1
• Re-evaluate after 2-3 weeks: If no response, discontinue medication immediately—do NOT increase doses 1
• Consider airway hyperresponsiveness testing in children >6 years if asthma is clinically suspected 4

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Critical Pitfalls to Avoid

• Do NOT use adult cough management approaches in pediatric patients 1
• Do NOT empirically treat for asthma, GERD, or upper airway cough syndrome unless specific clinical features support these diagnoses 4, 1
• Do NOT diagnose asthma based on cough alone: Chronic cough without wheeze is not associated with airway inflammation profiles suggestive of asthma 3
• Do NOT routinely perform additional tests (skin prick test, Mantoux, bronchoscopy, chest CT) unless specifically indicated by clinical findings 4
• Do NOT prescribe OTC medications due to parental pressure despite lack of efficacy 1

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Age-Specific Considerations

Children Under 2 Years

• Absolute contraindication to OTC cough and cold medications due to lack of proven efficacy and potential for serious toxicity 3
• Between 1969-2006: 54 fatalities associated with decongestants and 69 with antihistamines in children under 6 years 3
• Major pharmaceutical companies voluntarily removed cough and cold medications for children under 2 years from the OTC market in 2007 3
• Supportive care only: Gentle nasal suctioning, adequate hydration, and addressing parental concerns 3

Children 2-6 Years

• Honey remains the only recommended treatment for acute cough 1
• OTC medications still not recommended due to lack of efficacy and safety concerns 1

Children Over 6 Years

• Spirometry testing becomes feasible and should be performed for chronic cough 4
• Airway hyperresponsiveness testing should be considered if asthma is suspected 4

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When to Re-evaluate

• Re-evaluate if cough persists beyond 2-4 weeks for emergence of specific etiological pointers 1
• If empirical trial is used: Must be of defined limited duration (2-4 weeks maximum) to confirm or refute the hypothesized diagnosis 4, 1
• Review the child if deteriorating or not improving after 48 hours of treatment 1

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Environmental and Supportive Measures

• Evaluate and address tobacco smoke exposure in all children with cough 1
• Assess parental expectations and concerns as part of the clinical consultation 4, 1
• Ensure adequate hydration to help thin secretions 3
• Provide information about managing fever, preventing dehydration, and identifying signs of deterioration 3