What are the appropriate medications and dosing for an acute (<3 weeks) dry or productive cough in adults and children, including contraindications and red‑flag considerations?

Medication for Acute Cough in Adults and Children

For Acute Cough (<3 Weeks): Symptomatic Treatment Only

For acute viral cough in adults and children, avoid antibiotics and most cough suppressants; instead, use simple supportive measures and consider first-generation antihistamine-decongestant combinations for adults with common cold symptoms. 1, 2

Adults with Acute Cough

Primary approach:

• First-generation antihistamine plus decongestant is the most effective treatment for cough due to common cold 2
• Dextromethorphan 60 mg (higher than typical OTC dosing) shows dose-response effect with maximum cough suppression; can be given every 6-8 hours 1, 3
• Menthol inhalation (menthol crystals or proprietary capsules) provides acute but short-lived cough suppression 1
• Honey and lemon as a simple home remedy is reasonable and cost-effective 1

What NOT to prescribe:

• No antibiotics - they provide minimal benefit and expose patients to adverse effects 1, 4
• No codeine or pholcodine - these have no greater efficacy than dextromethorphan but significantly more adverse effects 1
• No routine bronchodilators - there is no role for bronchodilator therapy in uncomplicated acute bronchitis 4
• No expectorants or mucokinetic agents - they show no consistent favorable effect 4

Children with Acute Cough

Primary approach:

• Watchful waiting with supportive care is recommended 5
• Minimize environmental irritants, especially tobacco smoke exposure 5
• Adequate hydration to help thin secretions 5

What NOT to prescribe:

• No over-the-counter cough and cold medications in children <6 years due to lack of efficacy and risk of adverse events 5
• No antihistamines or β-agonists for acute viral cough - they provide no benefit and carry risk of adverse events 5

FDA-Approved Dosing for Specific Agents

Dextromethorphan (when indicated): 3

• Adults and children ≥12 years: 10 mL every 12 hours (max 20 mL/24 hours)
• Children 6 to <12 years: 5 mL every 12 hours (max 10 mL/24 hours)
• Children 4 to <6 years: 2.5 mL every 12 hours (max 5 mL/24 hours)
• Children <4 years: Do not use

Codeine (if prescribed despite limited evidence): 6

• Adults and children ≥12 years: 10 mL (2 tsp) every 4 hours (max 6 doses/24 hours)
• Children 6 to <12 years: 5 mL (1 tsp) every 4 hours (max 6 doses/24 hours)
• Children <6 years: Consult a doctor

Benzonatate: 7

• Adults and children >10 years: 100-200 mg three times daily as needed (max 600 mg/day)
• Must be swallowed whole - not to be broken, chewed, dissolved, cut, or crushed

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For Subacute/Post-Infectious Cough (3-8 Weeks)

Inhaled ipratropium bromide is the primary evidence-based treatment for post-infectious cough at this stage. 1, 4

Adults with Subacute Cough

First-line therapy:

• Inhaled ipratropium bromide - Grade A recommendation from ACCP 1, 4
• If ipratropium fails and cough adversely affects quality of life, consider inhaled corticosteroids 1
• For severe paroxysms after ruling out other causes: Prednisone 30-40 mg daily for a short, finite period 1
• Central antitussives (codeine or dextromethorphan) should be considered only when other measures fail 1

Children with Subacute Cough

Management algorithm:

• Watchful waiting with supportive care and reassessment if cough persists beyond 4 weeks 5
• Minimize environmental irritants, particularly tobacco smoke 5
• Scheduled follow-up at 4 weeks is mandatory - at this point it becomes chronic cough requiring systematic evaluation 5

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Red-Flag Considerations Requiring Different Management

In Adults:

• ACE inhibitor use - stop the medication regardless of temporal relationship; cough typically resolves within days to 2 weeks (median 26 days) 1
• Current cigarette smoker - smoking cessation is almost always effective; majority resolve within 4 weeks 1
• Fever, sweats, weight loss - suggests serious underlying disease requiring investigation 1
• Hemoptysis, recurrent pneumonia - requires chest CT and advanced evaluation 8

In Children:

• Wet or productive cough - suggests protracted bacterial bronchitis; treat with 2 weeks of amoxicillin or amoxicillin-clavulanate targeting S. pneumoniae, H. influenzae, M. catarrhalis 1, 5
• Cough during feeding - raises suspicion for aspiration 1, 5
• Digital clubbing - indicates chronic suppurative lung disease, bronchiectasis, or cystic fibrosis 1, 5
• Failure to thrive - may signal tuberculosis or cystic fibrosis 5
• Paroxysmal cough with post-tussive vomiting or inspiratory whoop - suspect pertussis and initiate macrolide antibiotics even before confirmation 1, 5, 4

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Critical Pitfalls to Avoid

• Do not prescribe antibiotics based on purulent sputum alone - purulence occurs from inflammatory cells and does not reliably differentiate viral from bacterial infection 4
• Do not empirically treat for asthma in children based solely on cough - cough sensitivity and specificity for asthma are poor 5
• Do not dismiss prolonged cough as "post-viral" without follow-up - 18% of children with chronic cough algorithms had serious progressive respiratory illnesses 5
• Do not use sedating antihistamines during daytime - reserve for nocturnal cough only due to drowsiness 1
• Do not continue ineffective therapies - if ipratropium fails and cough persists beyond 3 weeks, reassess rather than adding multiple symptomatic agents 4

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Patient Education and Expectations

• Acute viral cough typically lasts 2-3 weeks total from symptom onset, with symptoms peaking at days 3-6 4, 9
• 90% of viral coughs resolve by day 21, though 10% may persist beyond 25 days 5
• Transient bronchial hyperresponsiveness can persist for 2-3 weeks, occasionally up to 2 months 4
• Voluntary cough suppression may be sufficient to reduce cough frequency through central modulation of the cough reflex 1