Management of Persistent Nighttime Cough in a 10-Month-Old Infant
Stop the montelukast immediately and do not use any over-the-counter cough medications—this infant requires supportive care only, with reassessment at 2–4 weeks if the cough persists. 1, 2
Why Montelukast Should Be Discontinued
Montelukast is not effective for post-viral cough in infants. The largest multicenter trial (n=979) in children aged 3–24 months with post-RSV bronchiolitis found no significant difference in symptom-free days between montelukast and placebo over 4 weeks of treatment. 3
The FDA issued a black box warning in March 2020 for montelukast due to serious neuropsychiatric adverse effects, and current asthma guidelines specifically note this warning when discussing montelukast use in young children. 1
Montelukast has no role in treating isolated cough without wheeze or other asthma features. This infant has no wheezing, no respiratory distress, and no other signs suggesting asthma—montelukast should only be considered when there is evidence of recurrent wheeze or dyspnea, not for cough alone. 1, 2
What NOT to Do
Do not use any over-the-counter cough and cold medicines in this 10-month-old infant—they have no proven efficacy and carry significant risk of morbidity and mortality in children under 2 years. 1, 2, 4
Do not start inhaled corticosteroids based on isolated nighttime cough without evidence of asthma (no wheeze, no dyspnea, no bronchodilator response). 2, 5
Do not prescribe antibiotics for this viral-appearing cough without fever, purulent nasal discharge, or other signs of bacterial superinfection. 2, 5
Never give honey to an infant under 12 months of age due to the risk of infant botulism. 2
Appropriate Supportive Care
Ensure adequate hydration to help thin secretions and maintain comfort. 5
Use saline nasal irrigation followed by gentle aspiration to clear nasal passages if nasal congestion is contributing to nighttime cough. 4
Consider a cool-mist humidifier in the infant's room to help thin secretions. 4
Eliminate tobacco smoke exposure and other environmental irritants. 2, 4
Maintain safe sleep practices: place the infant on their back on a firm, flat surface without pillows or soft bedding, even when congested. 4
When to Reassess
Review the infant at 48 hours if symptoms are deteriorating or not improving, looking for signs of respiratory distress (respiratory rate >70 breaths/min, difficulty breathing, grunting, poor feeding, or cyanosis). 5, 4
Reassess at 2–4 weeks if the cough persists, as most post-viral coughs in infants resolve within 1–3 weeks without intervention. 2, 5
At 4 weeks duration, the cough becomes "chronic" and requires systematic evaluation including a chest radiograph to look for specific cough pointers such as feeding-related cough, digital clubbing, or failure to thrive. 2, 5
Red Flags Requiring Urgent Evaluation
Respiratory distress: respiratory rate >70 breaths/min, difficulty breathing, grunting, or cyanosis. 4
Poor feeding or signs of dehydration. 4
Persistent high fever (though this infant currently has no fever). 4
Important Clinical Caveats
Nocturnal cough reporting by parents is unreliable, with subjective reports correlating poorly with objective cough measurements (Cohen's kappa 0.3)—do not base clinical decisions solely on nighttime symptom descriptions. 5
The natural history of post-viral cough favors spontaneous resolution within 3–4 weeks, and the placebo response in pediatric cough studies approaches 80%. 2, 5
This clinical picture is most consistent with a self-limited post-viral cough given the absence of fever, rhinorrhea, clubbing, and other concerning features. 2, 5
Consider pertussis if there is known exposure, even in fully immunized infants, as partial vaccine failure can occur—but the absence of the characteristic paroxysmal cough with inspiratory whoop makes this less likely. 5