How should I manage a dry cough in a healthy 0-12-month-old infant with no fever, wheezing, respiratory distress, vomiting, apnea, or dehydration?

Management of Dry Cough in Healthy Infants (0-12 Months)

For a healthy infant with isolated dry cough and no concerning features, provide supportive care only and avoid all medications—this is a self-limited viral illness that will resolve spontaneously within 1-3 weeks in 90% of cases. 1

Immediate Management: Supportive Care Only

• Maintain adequate hydration through continued breastfeeding or formula feeding to help thin secretions 1, 2
• Use saline nasal drops to relieve nasal congestion that may contribute to post-nasal drip and cough 1
• Elevate the head of the crib during sleep to improve comfort and breathing 1
• Eliminate environmental irritants, particularly tobacco smoke exposure and other pollutants 1, 2
• Gentle nasal suctioning may help improve breathing if significant nasal congestion is present 2

What NOT to Prescribe

• Do NOT prescribe over-the-counter cough and cold medications in children under 6 years due to lack of efficacy and risk of serious adverse events, including 43 deaths in infants under 1 year from decongestants alone 1, 2
• Do NOT prescribe codeine-containing medications due to potential for serious side effects including respiratory depression 1
• Do NOT prescribe antibiotics at this initial presentation—a dry cough with clear breath sounds in an afebrile infant is consistent with viral infection and does not warrant antibiotics 1, 2
• Do NOT prescribe asthma medications (β-agonists or inhaled corticosteroids) unless other features of asthma are present, such as recurrent wheeze or dyspnea; isolated dry cough is rarely asthma in infants 3, 1

The evidence strongly cautions against over-diagnosing asthma based on cough alone. Studies show that cough sensitivity and specificity for wheeze is poor (34% and 35% respectively), and airway profiles in children with isolated chronic cough show very few with inflammation consistent with asthma 3. The CHEST guidelines explicitly state that "chronic cough is not associated with cell profiles suggestive of asthma and in isolation should not be treated with prophylactic anti-asthma drugs" 3.

Expected Clinical Course

• Most viral-associated coughs resolve within 7-10 days, with 90% of children cough-free by day 21 1, 2
• 10% of infants may cough for 20-25 days following an upper respiratory infection, which is still within normal limits 3, 2
• This represents either post-viral cough or acute bronchitis, both of which are self-limited 1

Red Flags Requiring Immediate Return

Parents should return immediately if any of the following develop:

• Respiratory distress (grunting, nasal flaring, intercostal retractions) 1, 2
• Fever develops (any fever in infants under 3 months warrants immediate evaluation) 1, 2
• Oxygen saturation drops below 92% (if measured at home) 1, 2
• Paroxysmal cough with post-tussive vomiting or inspiratory "whoop" suggesting pertussis 1, 2
• Inability to feed or signs of dehydration (decreased wet diapers, sunken fontanelle, lethargy) 1, 2
• Respiratory rate >70 breaths/min in infants 2
• Cyanosis or difficulty breathing 2

When to Reassess: The 4-Week Threshold

• If cough persists beyond 3-4 weeks, this transitions from acute to "prolonged acute cough" and warrants further evaluation 3, 1, 2
• At 4 weeks duration, the cough becomes "chronic" and requires systematic evaluation including chest radiograph and evaluation for underlying disease 3, 1, 4
• Do NOT use empirical treatment for upper airway cough syndrome, gastroesophageal reflux, or asthma unless specific clinical features support these diagnoses 3, 1, 4

At the 4-week mark, obtain a chest radiograph to identify structural abnormalities, pneumonia, or foreign body 1, 4. Classify the cough as wet/productive versus dry to guide further management 4. If the cough becomes wet/productive after 4 weeks, consider protracted bacterial bronchitis and initiate a 2-week course of antibiotics targeting common respiratory bacteria (Streptococcus pneumoniae, Haemophilus influenzae, Moraxella catarrhalis) 1, 2.

Special Considerations for Pertussis

• Consider pertussis if the cough pattern changes to paroxysmal episodes with post-tussive vomiting, especially if vaccination status is incomplete 3, 1
• The median duration of pertussis cough in vaccinated infants is 29-39 days, and 52-61 days in unvaccinated infants 3
• Pertussis can present as chronic cough without classic "whooping" in partially immunized infants 3

Common Pitfalls to Avoid

• Over-diagnosing asthma in infants with isolated dry cough—most children with isolated cough do not have asthma, and only about a quarter of children with cough symptoms actually have asthma 3, 1
• Prescribing empirical asthma medications without evidence of airway obstruction or wheeze 3, 1
• Using cough suppressants like dextromethorphan, as they have not been shown to be effective in children and are not recommended under age 6 years 1
• Assuming colored nasal discharge indicates bacterial infection—color does not reliably distinguish viral from bacterial infection in young children 2

Parent Education

• Explain that this is a self-limited viral illness that will resolve in 7-10 days in most cases 1, 2
• Provide clear instructions on warning signs requiring immediate return (listed above) 1, 2
• Emphasize hand hygiene and avoiding contact with sick individuals to prevent spread 1
• Reassure that no medication is needed or beneficial at this stage—supportive care is the appropriate evidence-based approach 1, 2
• Address parental anxiety about the cough's impact on sleep and feeding, as this often drives inappropriate medication use 2