Management of Cough in Infants Under 12 Months
For an infant under 12 months with cough and no red-flag features, provide supportive care only—do not use over-the-counter cough and cold medications, as they lack proven efficacy and carry serious safety risks including death. 1
What NOT to Do
Never administer OTC cough and cold medications (decongestants, antihistamines, cough suppressants, expectorants) to infants under 2 years of age. Between 1969-2006, there were 54 deaths associated with decongestants in children under 6 years, with 43 occurring in infants under 1 year, and 69 deaths from antihistamines, with 41 in children under 2 years. 1
Do not use topical decongestants in infants under 1 year due to narrow therapeutic margins and increased risk for cardiovascular and CNS toxicity. 1
Avoid empirical antibiotic treatment unless the cough becomes wet/productive and persists beyond 4 weeks, suggesting protracted bacterial bronchitis. 1
Do not diagnose or treat asthma based on cough alone in this age group—asthma medications should not be used unless other evidence of asthma is present (recurrent wheeze, dyspnea responsive to bronchodilators). 1
Supportive Care Measures
Ensure adequate hydration to help thin respiratory secretions and improve cough clearance. 1
Use acetaminophen for fever and discomfort to keep the infant comfortable and help reduce coughing episodes, but not solely to lower body temperature. 1
Gentle nasal suctioning may help improve breathing in infants with nasal congestion. 1
Maintain a supported sitting position to help expand lungs and improve respiratory symptoms if the infant has respiratory distress. 1
Eliminate environmental tobacco smoke exposure, which exacerbates respiratory symptoms and impairs secretion clearance. 1
Expected Clinical Course
Most acute viral coughs resolve within 1-3 weeks, though 10% may persist beyond 20-25 days. 1
90% of infants with bronchiolitis are cough-free by day 21 (mean resolution 8-15 days). 1
When to Seek Immediate Medical Attention
Parents should bring the infant to medical care immediately if any of these red-flag features develop:
- Respiratory rate >70 breaths/min 1
- Difficulty breathing, grunting, or cyanosis 1
- Oxygen saturation <92% (if measured) 1
- Not feeding well or signs of dehydration 1
- Persistent high fever ≥39°C for 3+ consecutive days 1
- Coughing with feeding (suggests aspiration) 2
- Digital clubbing 2
Follow-Up Timeline
Re-evaluate at 48 hours if symptoms are deteriorating or not improving. 1
At 3-4 weeks of persistent cough, this transitions to "prolonged acute cough" and warrants further evaluation. 1
At 4 weeks of persistent cough, this becomes "chronic cough" and requires systematic evaluation including:
Special Consideration for Pertussis
Consider pertussis testing when clinically suspected (paroxysmal cough, post-tussive emesis, inspiratory whoop). 2
For infants <1 month with suspected pertussis, azithromycin is preferred over erythromycin and clarithromycin due to better safety profile and no association with infantile hypertrophic pyloric stenosis. 2
Postexposure prophylaxis should be administered to infants <12 months exposed to pertussis due to risk of severe and sometimes fatal complications. 2
Common Pitfalls to Avoid
Do not assume colored nasal discharge indicates bacterial infection—this does not reliably distinguish viral from bacterial infection in young children. 1
Do not perform routine chest radiographs for uncomplicated upper respiratory infections, as they show abnormalities in up to 97% of infants who had a cold in the preceding 2 weeks, making them non-specific and unhelpful for management decisions. 1
Do not use chest physiotherapy—it is not beneficial and should not be performed in children with respiratory infections. 1