How should a cough and cold be managed in an infant under six months of age?

Management of Cough and Cold in Infants 0-6 Months

Do not use any over-the-counter cough and cold medications in infants under 6 months of age—these products lack proven efficacy and carry serious risks including death. 1, 2

Supportive Care Measures (First-Line Management)

The cornerstone of treatment is supportive care with the following specific interventions:

• Gentle nasal suctioning using a bulb syringe or nasal aspirator to clear secretions and improve breathing—this is one of the most effective interventions for nasal congestion 1, 2

• Maintain adequate hydration through continued breastfeeding or formula feeding, which helps thin secretions and prevents dehydration 1, 2

• Position the infant in a supported sitting position during feeding and rest to help expand the lungs and improve respiratory symptoms 1, 2

• Administer acetaminophen for fever (rectal temperature ≥100.4°F/38°C) and discomfort using weight-based dosing, which can help reduce coughing episodes 1, 2

Critical Safety Information

Between 1969-2006, there were 43 deaths from decongestants in infants under 1 year and 41 deaths from antihistamines in children under 2 years, leading major pharmaceutical companies to voluntarily remove these products from the market in 2007 1, 3. Controlled trials have consistently shown that antihistamine-decongestant combinations are ineffective for upper respiratory tract infections in young children 1, 3.

Red Flag Symptoms Requiring Immediate Medical Attention

Assess for the following warning signs that necessitate urgent evaluation:

• Respiratory rate >70 breaths/minute in the infant 1, 2
• Difficulty breathing, grunting, or cyanosis (blue discoloration of skin or lips) 1, 2
• Oxygen saturation <92% if measured 1
• Poor feeding or refusal of feeds—a critical warning sign in this age group 1, 2
• Signs of dehydration: decreased wet diapers, sunken fontanelle, no tears when crying 1
• Persistent high fever: rectal temperature ≥100.4°F (38°C) in infants under 3 months 1
• Intermittent apnea during the illness 2

Special Consideration: Pertussis (Whooping Cough)

Infants under 6 months are at the highest risk for severe pertussis complications and death 1. Consider pertussis if you observe:

• Paroxysmal cough (severe coughing fits)
• Post-tussive vomiting (vomiting after coughing)
• Inspiratory whoop 1

If pertussis is suspected or confirmed:

• For infants <1 month: Azithromycin is the preferred macrolide due to lower risk of infantile hypertrophic pyloric stenosis (IHPS) compared to erythromycin 4, 1
• For infants 1-5 months: Azithromycin or clarithromycin are first-line agents 4, 1
• Monitor all infants <1 month receiving macrolides for IHPS and other serious adverse events 4

The risk of acquiring severe pertussis and life-threatening complications outweighs the potential risk of IHPS in this vulnerable age group 4.

Antibiotic Use

• Do not prescribe antibiotics for viral upper respiratory infections, which represent the vast majority of coughs and colds 1, 2
• If bacterial pneumonia is suspected based on high fever, severe respiratory distress, and focal examination findings, amoxicillin 90 mg/kg/day divided twice daily is first-line therapy 1, 2

Chronic Cough (>4 Weeks)

If the cough persists beyond 4 weeks:

• Obtain a chest radiograph to rule out structural abnormalities, foreign body, pneumonia, or bronchiectasis 1, 2
• Evaluate for specific cough pointers: coughing with feeding, digital clubbing, failure to thrive 1
• Consider a 2-week trial of antibiotics targeting Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis for chronic wet cough without specific pointers 1

Medications and Therapies to Absolutely Avoid

• Never use honey in infants under 12 months due to botulism risk 1, 2
• Avoid codeine-containing medications due to potential for serious respiratory distress 1, 2
• Do not use topical decongestants in infants under 1 year due to narrow therapeutic window and risk of cardiovascular and CNS toxicity 1, 3
• Do not use empirical asthma treatment (such as salbutamol or bronchodilators) unless other features consistent with asthma are present 1, 2
• Chest physiotherapy provides no benefit and should not be performed 2

Prevention Strategies

• Emphasize hand hygiene with soap and water to prevent transmission of respiratory viruses 1
• Minimize exposure to tobacco smoke and other environmental irritants 1
• Ensure household contacts and caregivers are fully immunized, especially with pertussis and annual influenza vaccines, to create a protective "cocoon" around the infant who is too young to complete their own immunization series 1

Follow-Up

Reassess the infant if symptoms do not improve or if the infant deteriorates after 48 hours 2. The natural course of viral upper respiratory infections is generally mild and self-limited in otherwise healthy infants, but close monitoring is essential given their vulnerability 5, 6.