What are the appropriate cough medications for an adult with a dry or productive cough without red‑flag symptoms, and what special considerations apply for children and pregnant patients?

Cough Medication for Adults and Special Populations

Adults with Dry Cough (Non-Productive)

For adults with acute dry cough (<3 weeks), avoid routine prescription of antitussives or other medications, as most cases are viral and self-limiting. 1

Symptomatic Management

• Honey and lemon is recommended as first-line treatment for benign viral cough, as it is as effective as pharmacological treatments 1
• Dextromethorphan 30-60 mg may be used for short-term suppression only; the standard OTC dose is subtherapeutic, with maximum cough reflex suppression occurring at 60 mg 1
• Avoid codeine or codeine-containing products, as they have no greater efficacy than dextromethorphan but significantly more adverse effects 1

When Cough Becomes Chronic (>8 weeks)

• Systematic evaluation is mandatory including chest radiograph and spirometry 2
• Most cases reflect an underlying aggravant: asthma, ACE inhibitors, environmental exposures, gastroesophageal reflux, or upper airway pathology 2
• No patient with troublesome cough should continue ACE inhibitors 2
• Trial oral corticosteroids for 2 weeks if eosinophilic airway inflammation is suspected; cough is unlikely due to this if no response occurs 2

GERD-Related Cough

• Intensive acid suppression with proton pump inhibitors and alginates for minimum 3 months is recommended when GERD is suspected 2
• Reflux-associated cough may occur without gastrointestinal symptoms 2

Upper Airway Cough

• Trial topical corticosteroid in the presence of prominent upper airway symptoms 2

Adults with Productive Cough (Wet)

The presence of significant sputum production usually indicates primary lung pathology requiring investigation. 2

Initial Approach

• Chest radiograph and spirometry are mandatory 2
• Evaluate for chronic bronchitis, bronchiectasis, or other structural lung disease 2
• Smoking cessation should be strongly encouraged, as smoking is one of the commonest causes of persistent cough and appears dose-related 2

When to Suppress vs. Facilitate Cough

• Cough suppression may be relatively contraindicated when cough clearance is important for secretion management 2
• Guaifenesin carries FDA warnings to stop use if cough lasts more than 7 days or is chronic (as occurs with smoking, asthma, chronic bronchitis, or emphysema) 3

Children with Cough

Critical Age-Based Restrictions

Over-the-counter cough and cold medications should NOT be used in children under 2 years of age due to lack of proven efficacy and potential for serious toxicity. 4

• Between 1969-2006, there were 54 fatalities associated with decongestants in children under 6 years (43 deaths in infants under 1 year) 4
• 69 fatalities were associated with antihistamines in children under 6 years (41 deaths in children under 2 years) 4
• Major pharmaceutical companies voluntarily removed cough and cold medications for children under 2 years from the OTC market in 2007 4

Acute Cough in Children (<4 weeks)

• Supportive care only: antipyretics, analgesics, adequate hydration 4
• Avoid topical decongestants in children under 1 year due to narrow margin between therapeutic and toxic doses 4
• Most viral upper respiratory infections resolve within 1-3 weeks, with 10% of children still coughing at 25 days 4, 5

Chronic Wet/Productive Cough in Children (>4 weeks)

For children ≤14 years with chronic wet cough without specific cough pointers (coughing with feeding, digital clubbing), prescribe 2 weeks of antibiotics targeted to common respiratory bacteria (Streptococcus pneumoniae, Haemophilus influenzae, Moraxella catarrhalis). 2

• First-line antibiotic: Amoxicillin 45 mg/kg/day divided every 12 hours for children under 5 years 5
• If cough resolves within 2 weeks of antibiotics, diagnose protracted bacterial bronchitis (PBB) 2
• If wet cough persists after 2 weeks of appropriate antibiotics, treat with an additional 2 weeks 2
• If wet cough persists after 4 weeks of appropriate antibiotics, undertake further investigations (flexible bronchoscopy with quantitative cultures, chest CT) 2

Chronic Dry Cough in Children

• Do NOT use empirical trials for upper airway cough syndrome, GERD, or asthma unless specific clinical features support these diagnoses 2, 4
• Do NOT diagnose asthma based on cough alone; most children with isolated chronic cough do not have asthma 4
• Chest radiograph and spirometry (if age ≥6 years) are recommended 2, 4

Red Flags Requiring Immediate Investigation

• Coughing with feeding 2
• Digital clubbing 2
• Failure to thrive 4, 5
• Respiratory rate >70 breaths/min (infants) or >50 breaths/min (older children) 4
• Oxygen saturation <92% 4

Pregnant Patients

The provided guidelines do not contain specific recommendations for cough medication use in pregnancy. However, based on FDA labeling:

• Guaifenesin: FDA label states "If pregnant or breast-feeding, ask a health professional before use" 3
• Given the lack of specific guideline recommendations and general principles of medication safety in pregnancy, consultation with obstetrics is recommended before prescribing any cough medication

Safe Supportive Measures

• Honey and lemon (safe in pregnancy, effective for symptomatic relief) 1
• Adequate hydration 4
• Avoidance of environmental irritants and tobacco smoke 2

Common Pitfalls to Avoid

• Do not prescribe antibiotics reflexively for acute cough, as this contributes to antimicrobial resistance 1, 5
• Do not use subtherapeutic doses of dextromethorphan (standard OTC doses are ineffective) 1
• Do not continue ACE inhibitors in patients with troublesome cough 2
• Do not diagnose asthma in children based on cough alone without other features (recurrent wheeze, dyspnea responsive to bronchodilators) 4
• Color of nasal discharge does not distinguish viral from bacterial infection and should not guide antibiotic decisions 4, 5