How should I evaluate and manage an otherwise healthy child with an acute cough (≤2 weeks), including appropriate treatments and red‑flag signs?

Evaluation and Management of Acute Pediatric Cough (≤2 Weeks)

For an otherwise healthy child with acute cough lasting ≤2 weeks, provide supportive care with watchful waiting, avoid over-the-counter cough medications, and schedule mandatory follow-up at 4 weeks if the cough persists. 1

Initial Classification by Cough Character

The first critical step is determining whether the cough is wet/productive versus dry, as this fundamentally changes your management approach. 1, 2

Red-Flag Features Requiring Immediate Evaluation (Specific Cough)

Do not delay investigation if any of the following are present:

• Wet or productive cough – suggests protracted bacterial bronchitis or suppurative lung disease requiring immediate workup 1
• Coughing during feeding – raises concern for aspiration or swallowing dysfunction 1
• Digital clubbing – indicates chronic suppurative lung disease, bronchiectasis, or cystic fibrosis 1
• Failure to thrive or weight loss – may signal tuberculosis, cystic fibrosis, or other serious conditions 1
• Paroxysmal cough with post-tussive vomiting or inspiratory "whoop" – consider pertussis even in vaccinated children 1, 2
• Respiratory distress, hypoxia, or oxygen saturation <92% – requires urgent medical attention 3
• Persistent high fever ≥39°C for 3+ consecutive days – warrants urgent evaluation 3

Management of Non-Specific Dry Cough (No Red Flags)

Supportive Care Measures

• Honey (for children >1 year) is the only evidence-based symptomatic therapy, providing effective relief without adverse effects 1
• Adequate hydration to thin respiratory secretions 1, 3
• Minimize environmental irritants, particularly tobacco smoke exposure, which prolongs cough duration and worsens symptoms 1, 2
• Gentle nasal suctioning may help improve breathing in young infants 3

What NOT to Do

• Do not prescribe over-the-counter cough and cold medications in children under 6 years – they lack proven efficacy and carry risk of serious toxicity, including 54 deaths from decongestants and 69 deaths from antihistamines in children under 6 years between 1969-2006 3, 4, 5
• Do not prescribe antihistamines or β-agonists for acute viral cough – they provide no benefit and have adverse events 1
• Do not empirically treat for asthma based solely on cough – cough sensitivity and specificity for asthma are poor, and most isolated chronic coughs are not asthma 1, 2
• Do not empirically treat for GERD or upper-airway cough syndrome without specific supporting GI or upper airway features 6, 1

Expected Timeline

• 90% of viral coughs resolve by day 21 (mean resolution 8-15 days) 1
• 10% may persist beyond 25 days 1, 7
• Schedule mandatory follow-up at 4 weeks if cough persists, as this defines chronic cough requiring systematic evaluation 1, 2

Management of Specific Cough (Red-Flag Present)

Immediate Actions

• Obtain chest radiograph to detect structural abnormalities, pneumonia, foreign bodies, tuberculosis, or bronchiectasis 1, 2
• For wet/productive cough: Initiate a 2-week course of amoxicillin or amoxicillin-clavulanate targeting Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis when clinical suspicion for protracted bacterial bronchitis is high 6, 1, 2
• For suspected pertussis: Obtain nasopharyngeal aspirate or swab for culture/PCR and initiate macrolide antibiotics (azithromycin or erythromycin) immediately, even before confirmation 1

Referral Considerations

• Refer to pediatric pulmonology for infants <18 months with concerning features, when bronchoscopy may be needed, or when diagnosis remains unclear after initial evaluation 1

Critical Pitfalls to Avoid

• Do not dismiss prolonged cough as "post-viral" without follow-up – 18% of children evaluated with chronic-cough algorithms were later found to have serious progressive respiratory illnesses such as bronchiectasis, aspiration lung disease, or cystic fibrosis 1
• Do not use color of nasal discharge to distinguish viral from bacterial infection – this is unreliable in young children 3
• Do not perform chest physiotherapy – it is not beneficial and should not be performed in children with respiratory infections 3

Age-Specific Considerations

Infants (<1 Year)

• In infants, a "wet" cough does not involve visible sputum because they cannot expectorate; the term describes a loose, rattling sound generated by airway secretions 3
• Avoid topical decongestants in children under 1 year due to narrow therapeutic margin and risk for cardiovascular and CNS side effects 3
• Consider bronchiolitis if dry cough is accompanied by wheezing 3

Children 1-6 Years

• Pertussis should be strongly considered if the child lacks vaccination, as unvaccinated children have median cough duration of 52-61 days versus 29-39 days in vaccinated children 1
• Pertussis has an 80% secondary attack rate in susceptible contacts 1

Evaluation at 4 Weeks (Transition to Chronic Cough)

If cough persists to 4 weeks, systematic evaluation is mandatory:

• Chest radiograph 1, 2
• Spirometry (pre- and post-bronchodilator) for children ≥6 years who can perform reliable testing 1, 2
• Apply pediatric-specific cough algorithm differentiating wet/productive from dry cough 1, 2
• Assess cough impact on child and family quality of life 2

Parental Education

• Explain that acute cough is usually self-limited and part of normal viral illnesses 1
• Directly address parental concerns about impact on sleep, feeding, and daily activities, as anxiety often drives inappropriate medication use 1
• Educate about the risks of over-the-counter medications and lack of efficacy 4, 5
• Advise parents to seek immediate medical attention for respiratory rate >70 breaths/min (infants) or >50 breaths/min (older children), difficulty breathing, grunting, cyanosis, poor feeding, or signs of dehydration 3