What antitussive is recommended for pediatric patients, including age‑specific options and safety considerations?

Effective Antitussive for Pediatric Patients

Honey is the only evidence-based antitussive recommended for children over 1 year of age, while over-the-counter cough medicines should be avoided in all pediatric patients due to lack of efficacy and significant safety concerns. 1

Recommended Treatment by Age

Children > 1 Year Old

• Honey is the first-line and only recommended antitussive, providing superior cough relief compared to diphenhydramine, placebo, or no treatment 1, 2, 3
• Administer honey for acute cough symptoms in children over 12 months 1, 2
• Never give honey to infants under 12 months due to risk of infant botulism 1

Children < 2 Years Old

• All over-the-counter cough and cold medicines are contraindicated in this age group 3
• The FDA issued safety warnings and manufacturers withdrew OTC formulations for children under 2 years in 2007 3
• Supportive care and watchful waiting are appropriate for most acute coughs, which are typically self-limiting viral infections 3

Children 2-6 Years Old

• OTC cough medicines remain not recommended despite some product labels permitting use at age 2 1
• Clinical guidelines state that OTC cough products provide minimal to no proven benefit in this age range 1
• Honey remains the only evidence-based option for children over 1 year 1

Medications That Must Be Avoided

Absolutely Contraindicated

• Codeine-containing medications are prohibited in all pediatric patients due to risk of serious respiratory depression and death; the FDA (2018) restricted prescription opioid cough medicines to adults ≥18 years only 1, 3
• Promethazine is contraindicated for use in children less than 2 years of age 4

Not Recommended (No Efficacy)

• Dextromethorphan is no more effective than placebo for reducing nocturnal cough or sleep disturbance and should not be used in children 1, 2
• Antihistamines have minimal to no efficacy for cough relief and are associated with adverse events, including 69 reported fatalities in children under 6 years between 1969-2006 1, 3
• Decongestants caused 54 fatalities in children under 6 years and can cause severe neuropsychiatric events (agitated psychosis, ataxia, hallucinations) and cardiovascular toxicity 1
• Over-the-counter cough and cold medicines have not demonstrated reduction in cough severity or duration and are linked to significant morbidity and mortality 1, 2, 3

Management Algorithm for Chronic Cough (≥4 Weeks)

Initial Assessment

• Obtain chest radiograph as baseline study at 4 weeks 5, 1
• Perform spirometry (pre- and post-β2 agonist) in children ≥6 years when age-appropriate 5, 1
• Assess for specific "cough pointers" such as coughing with feeding, digital clubbing, productive/wet cough, or failure to thrive 5, 2

Treatment Based on Cough Characteristics

• Wet/productive cough >4 weeks: Consider 2-week course of antibiotics targeting Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis 1
• Dry cough with asthma risk factors: Trial of low-dose inhaled corticosteroids (400 μg/day budesonide or beclomethasone equivalent) for 2-4 weeks 1, 2, 3
• Re-evaluate after 2-4 weeks: If cough persists, discontinue medication and do not increase dose 1, 2, 3

What NOT to Do

• Do not use empirical treatment for asthma, GERD, or upper airway cough syndrome without specific clinical features supporting these diagnoses 5, 1, 2
• Do not use acid suppressive therapy solely for chronic cough; GERD treatment should only be considered when gastrointestinal symptoms (recurrent regurgitation, dystonic neck posturing in infants, heartburn/epigastric pain in older children) are present 5, 1
• Do not use adult cough management approaches in pediatric patients, as etiologies and effective treatments differ markedly 1, 2

Special Considerations for Pertussis

When pertussis is confirmed or suspected:

• Macrolide antibiotics (erythromycin 40-50 mg/kg/day, azithromycin, or clarithromycin) should be initiated immediately 5
• Treatment is most effective when started within the first 2 weeks (catarrhal phase) to diminish coughing paroxysms and prevent spread 5
• Isolate patient for 5 days after starting antibiotic therapy 5
• Long-acting β-agonists, antihistamines, corticosteroids, and pertussis immunoglobulin should NOT be used as they provide no benefit 5

Environmental Modifications

• Eliminate tobacco smoke exposure in all children with cough 1, 2, 3
• Assess and address other environmental pollutants and allergens 1, 2
• Provide parental education about natural course of viral illness and expected resolution timeframes 1, 3

Critical Pitfalls to Avoid

• Prescribing OTC medications due to parental pressure despite lack of efficacy 1
• Using medications that have been shown equivalent to placebo (dextromethorphan, antihistamines) 1, 2
• Failure to re-evaluate children whose cough persists beyond 2-4 weeks 1, 2, 3
• Prolonged use of inhaled corticosteroids without clear evidence of asthma 2
• Treating GERD empirically without gastrointestinal symptoms 5
• Applying adult treatment algorithms to pediatric patients 1, 2

Follow-Up Recommendations

• Re-evaluate at 2-4 weeks if cough persists, looking for emerging specific etiologic pointers 1, 2, 3
• Most acute viral coughs resolve within 1-3 weeks without specific treatment 1, 3
• If medications are prescribed, discontinue if no effect is observed within the expected timeframe 2
• Consider referral to pediatric pulmonology when cough persists despite appropriate management or when red-flag signs emerge 2