Recommended First-Line Antitussive for Pediatric Patients
There is no recommended first-line antitussive for pediatric cough, as over-the-counter cough medications should not be prescribed for children, particularly those under 4 years of age, due to lack of efficacy and potential for serious adverse events including death. 1
Evidence Against OTC Antitussives in Children
The CHEST guidelines explicitly state that OTC cough medications have little, if any, benefit in symptomatic control of acute cough in children, and preparations containing antihistamine and dextromethorphan are associated with adverse events. 1
The FDA issued warnings against using OTC cough and cold medications in young children, and manufacturers voluntarily relabeled these products with "do not use in children under 4 years of age." 1
In 2018, the FDA further restricted prescription opioid cough and cold medicines to adults ≥18 years only, eliminating codeine as an option for pediatric patients. 1
Codeine-containing medications should be avoided in children because of potential for serious side effects including respiratory distress. 1
Age-Specific Contraindications
Dextromethorphan is contraindicated in children under 4 years of age per FDA labeling. 2
For children 4 to under 6 years: 2.5 mL every 12 hours (maximum 5 mL in 24 hours), though evidence of efficacy remains absent. 2
For children 6 to under 12 years: 5 mL every 12 hours (maximum 10 mL in 24 hours). 2
Alternative Supportive Measures
Honey may offer more relief for cough symptoms than no treatment, diphenhydramine, or placebo in children, but it is not superior to dextromethorphan. 1
Honey should only be used in children >1 year of age due to botulism risk (general medical knowledge).
Topically applied vapor rubs may provide some symptomatic relief, though evidence is limited. 3
Critical Pitfalls to Avoid
Do not prescribe OTC cough medications routinely, especially in children under 2 years of age, as the risk of adverse events including death outweighs any potential benefit. 1, 4
Do not use antihistamines, as efficacy data in children is minimal if present at all, contrasting with adult data. 1
Do not use corticosteroids, long-acting β-agonists, or other symptomatic therapies for non-specific cough, as these have no proven benefit. 1
When Antitussives Are Never the Answer
For pertussis-associated cough, dexamethasone provides no significant benefit for symptomatic relief, and antibiotics (azithromycin) do not alter the clinical course of established paroxysmal coughing once it begins. 1, 5
Therapies such as antihistamines, corticosteroids, and pertussis immunoglobulin have no significant benefit in controlling pertussis coughing paroxysms. 6
Clinical Approach
Focus on identifying and treating the underlying cause of cough rather than suppressing the symptom. 1
For acute viral URI-associated cough, reassure families that most episodes are self-limited and will resolve spontaneously. 3
Balance any consideration of antitussive use with the documented adverse events, which include reported deaths from toxicity in young children. 1