What is the recommended treatment for cough and congestion in children under 6 years old?

Treatment of Cough and Congestion in Children Under 6 Years

Do not use over-the-counter cough and cold medications in children under 6 years of age—these medications lack proven efficacy and have caused deaths in this age group. 1, 2, 3

Recommended First-Line Treatment

For children over 1 year old with acute cough, honey is the only recommended pharmacologic treatment, providing more relief than no treatment, diphenhydramine, or placebo. 1, 2

• Critical safety warning: Never give honey to infants under 12 months of age due to risk of infant botulism. 1
• Typical dosing: 2.5-5 mL as needed for cough symptoms 1

Supportive Care Measures (All Ages)

For all children under 6 years with cough and congestion, implement these evidence-based supportive measures:

• Nasal saline irrigation with gentle bulb syringe aspiration effectively clears secretions and improves breathing 2, 3, 4
• Maintain adequate hydration through continued breastfeeding or formula feeding to thin secretions 2, 3
• Upright positioning during feeding and rest helps expand lungs and improve respiratory symptoms 2, 3
• Weight-based acetaminophen for fever and discomfort, which can indirectly reduce coughing episodes 2

Medications to AVOID

Absolutely Contraindicated:

• Over-the-counter cough and cold medications: Not effective and associated with 54 documented deaths in children under 6 years between 1969-2006, including 43 deaths in infants under 1 year. 2, 3, 5
• Codeine-containing medications: Must be avoided due to serious side effects including respiratory distress and death. The FDA restricts prescription opioid cough medicines to adults ≥18 years only. 1, 2, 6
• Dextromethorphan: No different than placebo in reducing nocturnal cough or sleep disturbance in children. 1, 7
• Antihistamines: Minimal to no efficacy for cough relief and associated with adverse events, particularly when combined with other OTC ingredients. 1, 5
• Oral decongestants (phenylephrine, pseudoephedrine): Caused 4 phenylephrine-related deaths and 43 total decongestant deaths in infants under 1 year, with serious neurological and cardiovascular toxicity. 2, 3

When to Consider Antibiotics

Antibiotics are NOT indicated for viral upper respiratory infections (the vast majority of coughs and colds). 2 However, consider antibiotics in these specific scenarios:

• High fever ≥38.5°C persisting >3 days: Consider beta-lactam antibiotics 1
• Chronic wet/productive cough >4 weeks without specific pointers: 2-week course targeting Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis 8, 1
• Clinically and radiologically confirmed pneumonia: Amoxicillin 80-100 mg/kg/day in three divided doses as first-line in children under 3 years 1
• Persistent purulent nasal discharge or confirmed sinusitis: 10-day antimicrobial course (number needed to treat = 8) 1

When to Re-Evaluate or Escalate Care

Re-evaluate if cough persists beyond 2-4 weeks for:

• Emergence of specific pointers: wheeze, crepitations, chest radiograph abnormalities 8, 1, 2
• Consider protracted bacterial bronchitis, pertussis (especially if paroxysmal), or aspiration 8, 2

Immediate medical attention required for:

• Respiratory rate >70 breaths/minute 2
• Difficulty breathing, grunting, or cyanosis 2
• Oxygen saturation <92% 2
• Poor feeding or dehydration signs (decreased wet diapers, sunken fontanelle, no tears) 2
• Persistent high fever (rectal temperature ≥100.4°F/38°C) 2

Chronic Cough Management (>4 weeks)

For children with chronic cough, use a systematic pediatric-specific approach:

• Mandatory investigations for children ≥6 years: Chest radiograph and spirometry (pre- and post-β2 agonist) 8, 1
• Determine if cough is wet/productive versus dry, as this guides further management 8, 1
• Do NOT empirically treat for asthma, GERD, or upper airway cough syndrome unless specific clinical features support these diagnoses 8, 1

If asthma suspected with risk factors:

• Consider 2-3 week trial of low-dose inhaled corticosteroids (400 μg/day budesonide or beclomethasone equivalent) 1
• Reassess after 2-3 weeks: If cough unresponsive to ICS, do NOT increase doses—discontinue and consider other diagnoses 1

GERD considerations:

• Do NOT treat GERD when there are no GI clinical features (recurrent regurgitation, dystonic neck posturing in infants, heartburn/epigastric pain in older children) 8, 1
• Do NOT use acid suppressive therapy solely for chronic cough—it is not effective 8, 1
• Proton pump inhibitors in infants increase serious adverse events, particularly lower respiratory tract infections (OR 6.56) 2

Common Pitfalls to Avoid

• Using adult cough management approaches in pediatric patients 8, 1
• Prescribing OTC medications due to parental pressure despite lack of efficacy 1, 5
• Failure to re-evaluate children whose cough persists despite treatment 1
• Topical decongestants in infants under 1 year: Narrow therapeutic window with risk of cardiovascular and CNS toxicity; rebound congestion (rhinitis medicamentosa) can occur as early as 3-4 days 2

Environmental Modifications

• Evaluate and address tobacco smoke exposure and other environmental pollutants in all children with cough 8, 1
• Assess parental expectations and concerns as part of the clinical consultation—parents who desire medication at initial visit report more improvement at follow-up regardless of whether child received medication, placebo, or no treatment 1