What can be offered to a 14‑year‑old with cough who has tested negative for streptococcal pharyngitis, COVID‑19, and influenza?

Management of Cough in a 14-Year-Old with Negative Strep, COVID-19, and Influenza Testing

For a 14-year-old with cough who has tested negative for streptococcal pharyngitis, COVID-19, and influenza, start with simple supportive measures including honey for symptomatic relief, ensure adequate hydration, and use a systematic approach to determine if this is acute post-viral cough (which typically resolves within 1-3 weeks) or requires further evaluation if symptoms persist beyond 4 weeks. 1, 2

Initial Supportive Care Measures

• Honey is the first-line symptomatic treatment for cough in patients over 1 year of age, as it provides effective relief without the risks associated with over-the-counter cough medications 1

• Ensure adequate hydration to help thin secretions and improve cough effectiveness 1, 2

• Advise the patient to avoid lying flat on their back, as this position makes coughing less effective 1

• If fever is present, paracetamol (acetaminophen) can be used for symptomatic relief, but should not be used solely to reduce body temperature 1

What NOT to Do

• Do not use over-the-counter cough and cold medications, as they lack proven efficacy in children and adolescents and carry potential safety concerns 2

• Do not prescribe antibiotics empirically unless specific features of bacterial infection develop (such as persistent high fever ≥39°C for 3+ days, respiratory distress, or hypoxia) 2, 3

• Do not start asthma medications (such as β-agonists or inhaled corticosteroids) unless there is clear evidence of asthma with features like recurrent wheeze, exercise intolerance, or documented bronchodilator responsiveness 2, 3

• Avoid empirical treatment for upper airway cough syndrome, gastroesophageal reflux, or asthma unless specific clinical features support these diagnoses 1, 3

Timeline for Monitoring and Escalation

• Most acute viral coughs resolve within 1-3 weeks, though 10% may persist beyond 20-25 days 2, 3

• If cough persists for 3-4 weeks, this transitions to "prolonged acute cough" and warrants closer monitoring 2, 3

• At 4 weeks duration, the cough becomes "chronic" and requires systematic evaluation including:

  • Chest radiograph to exclude structural abnormalities 1, 3
  • Spirometry (pre- and post-bronchodilator) to assess for obstructive patterns 1, 3
  • Classification as wet/productive versus dry cough to guide further management 1, 3

When to Seek Immediate Medical Attention

• Respiratory rate >50 breaths/min in this age group 2

• Difficulty breathing, grunting, or cyanosis 2

• Oxygen saturation <92% if measured 2

• Persistent high fever ≥39°C for 3+ consecutive days 2, 3

• Signs of dehydration or not feeding/drinking well 2

• Worsening symptoms or no improvement after 48 hours 2

Management Algorithm for Persistent Cough (≥4 Weeks)

If cough becomes wet/productive:

• Consider protracted bacterial bronchitis and prescribe a 2-week course of antibiotics targeting common respiratory bacteria (Streptococcus pneumoniae, Haemophilus influenzae, Moraxella catarrhalis) 2, 3
• First-line choice is amoxicillin or amoxicillin-clavulanate 2, 3

If cough remains dry:

• Evaluate for asthma only if specific features are present (wheezing, nocturnal symptoms, exercise intolerance, family history of atopy) 3
• Consider bronchial hyperreactivity testing if asthma is suspected 3

Important Caveats

• The color of nasal discharge does not distinguish viral from bacterial infection and should not guide antibiotic decisions 2

• Environmental tobacco smoke exposure should be identified and eliminated, as it exacerbates respiratory symptoms 2, 3

• If an empirical treatment trial is attempted based on specific clinical features, limit it to 2-4 weeks maximum to confirm or refute the diagnosis, avoiding prolonged ineffective treatments 3