What are the recommended over‑the‑counter cough treatments for infants (<12 months), children (1–12 years), adult men and women, and elderly women (≥65 years)?

Cough Medicine Recommendations by Age Group

Infants Under 12 Months

Do not use any over-the-counter cough medications or honey in infants under 12 months. 1

• Honey is absolutely contraindicated due to risk of infant botulism 1, 2
• OTC cough and cold medicines should not be used as they provide no proven benefit and carry significant risk of morbidity and mortality 1, 3
• Between 1969-2006,43 decongestant-related deaths occurred in infants under 1 year 3
• Supportive care only: ensure adequate hydration, nasal suctioning, and eliminate tobacco smoke exposure 1

Children 1-12 Years

Honey is the only recommended treatment for acute cough in children over 1 year of age. 1, 2

What Works:

• Honey provides superior relief compared to no treatment, diphenhydramine, or placebo 1, 2, 4
• Dosing: A single dose before bedtime (2.5-5 mL) has been shown to reduce cough frequency and improve sleep 5, 6
• Honey is as effective as dextromethorphan but safer given dextromethorphan's lack of proven efficacy 1, 2

What to Avoid:

• All OTC cough and cold medicines should not be used in children under 4 years 1, 3, 7
• Children 4-6 years: OTC medications remain not recommended despite some labeling permitting use at age 2 3
• Children ≥6 years: FDA labeling permits use 3, 7, but clinical benefit remains minimal 1
• Dextromethorphan provides no benefit over placebo and should be avoided at all pediatric ages 1
• Antihistamines have minimal to no efficacy and are associated with 69 reported fatalities in children under 6 years between 1969-2006 1, 3
• Codeine-containing products are absolutely contraindicated due to risk of respiratory depression and death; FDA restricted these to adults ≥18 years in 2018 1, 3

When to Re-evaluate:

• If cough persists beyond 2-4 weeks, re-evaluate for specific etiologic pointers 1, 2
• Red flags requiring immediate evaluation: cough with feeding, digital clubbing, failure to thrive, or productive cough 1
• For chronic cough (≥4 weeks), obtain chest radiograph and spirometry if age-appropriate (≥6 years) 1

Adult Men and Women

For adults, OTC cough medications may be used according to package directions, though evidence for efficacy remains limited. 3, 7

Available Options:

• Dextromethorphan: FDA-approved dosing is 10 mL every 12 hours, not to exceed 20 mL in 24 hours 7
• Honey remains a safe and effective option for symptomatic relief in adults 6
• Antihistamine-decongestant combinations may provide modest benefit, though controlled trials show limited effectiveness 3

Important Caveats:

• Avoid multiple products containing the same active ingredients to prevent unintentional overdose 3
• Decongestants can cause tachyarrhythmias, insomnia, and hyperactivity, especially when combined with stimulant medications 3
• Most acute coughs are self-limiting viral infections requiring only supportive care 1

Elderly Women (≥65 Years)

The same adult recommendations apply, but exercise increased caution with decongestants and antihistamines due to higher risk of adverse effects.

Special Considerations:

• First-generation antihistamines carry significant anticholinergic burden and should be avoided in elderly patients 3
• If antihistamines are necessary, second-generation agents (cetirizine, loratadine, fexofenadine) are preferable due to minimal cognitive and antimuscarinic effects 3
• Decongestants pose cardiovascular risks (tachyarrhythmias) and CNS effects that may be poorly tolerated 3
• Honey remains a safe, effective first-line option with no age-related contraindications 6, 8

Medication Review:

• Check for drug-drug interactions, particularly with cardiovascular medications and stimulants 3
• Monitor for adverse effects including confusion, urinary retention, and falls risk with first-generation antihistamines 3

Critical Safety Points Across All Ages

• Never use adult cough management approaches in children - etiologies and effective treatments differ markedly 1
• Codeine and prescription opioid cough medicines are restricted to adults ≥18 years only 1, 3
• Most acute coughs resolve spontaneously within 1-3 weeks and require only supportive care 1
• Tobacco smoke exposure should be evaluated and eliminated in all patients with cough 1