Cough Management in Children

Introduction to Cough Management

The American Thoracic Society recommends against prednisolone (and by extension, dexamethasone) as first-line treatment for most types of cough, reserving it only for specific conditions like cough variant asthma, eosinophilic bronchitis, or severe post-infectious cough that has failed other treatments 3
No evidence supports oral corticosteroids for nonspecific cough in children, and one randomized trial in children with wheeze showed oral steroids provided no benefit but were associated with a non-significant increase in hospitalizations (p=0.058) 1, 2

Acute cough (<3 weeks) is most likely viral upper respiratory infection; supportive care only is recommended, but for subacute cough (3-8 weeks), first-line treatment is inhaled ipratropium bromide, not oral steroids 4
Chronic cough (>8 weeks) requires systematic evaluation using pediatric-specific protocols 5, 6
Specific cough has associated features suggesting underlying disease (wet/productive cough, abnormal chest radiograph, spirometry showing obstruction, hemoptysis, digital clubbing, chest wall deformity, cardiac disease, or failure to thrive) 5, 7

For suspected asthma, consider a trial of inhaled corticosteroids (ICS), NOT oral dexamethasone: Use beclomethasone 400 mcg/day or budesonide equivalent for 2-4 weeks 8, 7, 2
Reassess in 2-4 weeks: If no response, stop the ICS and reconsider the diagnosis 7, 2
Do not escalate to higher ICS doses or add oral steroids if the initial trial fails 1, 2

Confirmed cough variant asthma or eosinophilic bronchitis may be treated with prednisolone 30 mg daily for 2 weeks as a diagnostic-therapeutic trial, with response expected within 3 days 3
Severe post-infectious cough may be treated with prednisolone 30-40 mg daily for a short, finite period, only after failure of inhaled ipratropium bromide and ICS 3, 4

Never use over-the-counter cough suppressants (codeine, dextromethorphan, diphenhydramine) in children, as they are associated with significant morbidity and mortality without proven benefit 7, 1
Do not prescribe antibiotics unless there is confirmed bacterial sinusitis, pertussis, or protracted bacterial bronchitis with wet cough 9, 4
Avoid prolonged use of inhaled corticosteroids without confirming asthma diagnosis, as cough may resolve spontaneously (period effect) 1, 2
Long-term systemic corticosteroid use carries significant side effects including growth suppression, bone density loss, and adrenal suppression that must be weighed against potential benefits 3