Is systemic prednisone recommended for a 9-year-old with persistent cough and mild nasal congestion?

Systemic Prednisone Is Not Recommended for This Clinical Presentation

Oral prednisone should not be given to a 9-year-old with persistent cough and mild congestion, as systemic corticosteroids are explicitly discouraged for routine management of pediatric cough and upper respiratory symptoms. 1, 2

Why Systemic Steroids Are Inappropriate

Lack of Efficacy in Pediatric Cough

• Oral corticosteroids confer no benefit for cough in children and have been associated with a nonsignificant increase in hospitalizations in pediatric studies 1
• Systemic corticosteroids do not improve recovery at 7-14 days in post-viral rhinosinusitis, which is the most likely diagnosis given the clinical picture of persistent cough with congestion 1
• The only modest benefit seen with oral steroids is a small reduction in facial pain at days 4-7, but this effect disappears by 10-14 days and is not relevant to isolated cough and congestion 1

Significant Adverse Effects in Children

• Behavioral side effects are particularly problematic in children receiving oral corticosteroids, with anxiety occurring twice as frequently and aggressive behavior being significantly more common (number needed to harm of 4.8 for aggressive behavior) 3
• Other adverse effects include hyperactivity, sleep disturbance, and mood changes that substantially impact quality of life 3
• The risk-benefit ratio strongly favors avoiding systemic steroids for this mild presentation 1, 3

What Should Be Done Instead

First-Line Approach: Supportive Care

• Honey (1-2 teaspoons as needed) is the only evidence-based treatment for cough in children over 1 year of age, providing superior relief compared to diphenhydramine, placebo, or no treatment 2, 4
• Adequate hydration, rest, and environmental modifications (eliminate tobacco smoke exposure) are essential supportive measures 5

For Nasal Congestion

• Intranasal corticosteroids (such as fluticasone 1 spray per nostril daily or mometasone) are the most effective medication class for controlling nasal congestion and should always be considered before systemic corticosteroids 1
• Fluticasone propionate is approved for children aged 4 years and older, making it appropriate for this 9-year-old 6
• Oral decongestants (pseudoephedrine or phenylephrine) can help reduce nasal congestion but may cause insomnia, loss of appetite, and irritability 1

When to Consider Inhaled Corticosteroids

• If the child has risk factors for asthma (personal atopy, family history, nocturnal cough, exercise-induced symptoms), a 2-4 week trial of low-dose inhaled corticosteroids (approximately 400 μg/day budesonide-equivalent) may be considered 1, 2
• Critical: Reassess after 2-3 weeks; if cough persists, stop the inhaled corticosteroid and do not increase the dose 1, 2
• If cough resolves, discontinue the medication and monitor to determine whether improvement was treatment-related or spontaneous 1, 2

Antibiotic Consideration

• If there is persistent purulent nasal discharge or radiographically confirmed sinusitis, a 10-day course of antibiotics (amoxicillin 80-100 mg/kg/day) reduces cough persistence, though the number needed to treat is 8 1, 7
• For acute cough from common colds without bacterial sinusitis, antimicrobials provide no benefit 1

Red Flags Requiring Further Evaluation

• Cough persisting beyond 4 weeks requires systematic evaluation with chest radiograph and spirometry (if age-appropriate) 2, 5
• Coughing with feeding, digital clubbing, productive cough, or failure to thrive mandate immediate comprehensive workup 2, 5
• Fever persisting >3 days or development of hemoptysis requires re-evaluation 5

Common Pitfalls to Avoid

• Do not prescribe systemic corticosteroids for mild upper respiratory symptoms in children, as they provide no meaningful benefit and cause significant behavioral side effects 1, 3
• Do not use over-the-counter cough and cold medicines in children, as they have not been shown to reduce cough severity or duration and are associated with significant morbidity 2
• Do not use antihistamines for cough relief, as they have minimal to no efficacy in children and are associated with adverse events 1, 2
• Do not apply adult cough-management approaches to pediatric patients, as etiologies and effective treatments differ markedly 2, 5
• Do not empirically treat for asthma, GERD, or upper airway cough syndrome without specific clinical features supporting these diagnoses 2, 5

When Systemic Steroids Might Be Appropriate (Not This Case)

• Oral prednisone (30-40 mg daily for 5-10 days) is reserved only for severe paroxysms of post-infectious cough that significantly impair quality of life, and only after ruling out upper airway cough syndrome, asthma, and GERD 5, 4
• A short course (5-7 days) may be appropriate for very severe or intractable rhinitis or nasal polyposis, but intranasal corticosteroids should always be tried first 1
• Single or recurrent administration of parenteral corticosteroids is contraindicated due to greater potential for long-term side effects 1