Cough

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Updated 31 August 2017

How to effectively treat acute coughs in children

Sponsored: Given that a cough can last up to four weeks, parents need to seek more effective treatment methods for their children.

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Cough in children

Coughs are common in school age children, occurring seven to 10 times a year.1Apgiii5 Cough is a particularly bothersome symptom that tends to resolve slowly; half of children recover after 10 days and 90% after 25 days, which means that 10% of children still cough three to four weeks after falling ill.1Bpgiii5

Although cough is an important reflex defence mechanism to protect a child’s lungs and keep them clear,2Apg14 it can have a major impact on a child’s sleep, school performance and ability to play.1Cpgiii1 A coughing child also disturbs other family members’ sleep and may be disruptive in the classroom, causing parents considerable anxiety.1Cpgiii1

What are the common causes of cough?

Cough is classified as acute or chronic.1Dpgiii2 An acute cough lasts less than three weeks.1D+Epgiii2 A chronic cough lasts more than eight weeks and is usually associated conditions such as asthma, allergy, post-viral cough and postnasal drip.1Dpgiii2,Fpgiii7

What is the difference between a wet and dry cough?

A wet cough is typically chesty and produces mucus.3Apg20 It may be difficult to be sure if a young child has a wet cough because most young children tend to swallow the mucus, which they often vomit up later.1Gpgiii10 A dry cough is tickly or irritating and no mucus is produced.3Apg20

When should parents be concerned about a child’s cough?

Most acute coughs are due to a simple upper respiratory tract infection.1Hpgiii5 However, children with any of the following signs should be taken to a doctor right away:4Apg2,Bpg3

• Blue tint to the lips and/or skin (cyanosis)

• Loud squeaking noise when breathing in (stridor)

• Difficulty breathing

• An ill appearance

• Spasms of uncontrollable, repetitive coughing followed by a high-pitched intake of air (whoop)

• Any child suspected of inhaling a foreign body (sudden onset of cough with no other symptoms)

• ‘Barking’ cough (croup)

• High fever or underlying lung disorders, e.g. asthma or cystic fibrosis

How is acute cough treated?

Acute cough following a upper respiratory tract infection is usually self-limiting but it can be difficult to control and significantly impair daily life.2Bpg14 Most acute coughs are caused by viruses, which makes antibiotics generally ineffective.1Ipgiii5

However, parents frequently seek over-the-counter (OTC) medicines to relieve their child’s cough.5Apg2

A recent survey of cough mixtures found no good evidence for or against the effectiveness of these medicines in acute cough.6Apg3 Furthermore, cough mixtures may contain a combination of different active ingredients that are potentially harmful to children.7A+Bpg175 Due to their small bodies and frequency of infections, young children are at higher risk of overdose, incorrect dosing, and side effects, especially if a cough mixture contains multiple ingredients.7Cpg175

A closer look at mucolytics: how they work and when to use them

Mucus in our lungs is held together by disulfide bonds.8Apg1184 Mucolytics work by breaking these bonds.8Apg1184 When these bonds are broken, the mucus becomes less sticky and less thick and is easier to cough up.9Apgs216 This can make it harder for germs to infect the mucus and cause chest infections.10Apg1 Mucolytics are useful to alleviate coughing, mucus production and airway obstruction.8Bpg1181

What is N-acetylcysteine (NAC)?

NAC is the most commonly used mucolytic to loosen secretions from the respiratory tract.11Apg106 Scientific studies have shown that NAC reduces cough and has good overall safety in children older than 2 years.2Cpg15,5Bpg2 Evidence also suggests that NAC makes it harder for bacteria to stick to the inside of the airways.8Cpg1187

Can I buy NAC?

Yes, you can buy NAC from your local pharmacy without a doctor’s prescription. NAC is available as an effervescent tablet and is suitable for children and adults – consult the label of the product before use.

What are some of the benefits of an effervescent tablet over a liquid formulation?

Studies have shown that more than 40% of parents make errors when dosing liquid formulations.12Apg1 This is not surprising, given that parents can choose from an array of dosing tools with which to administer the medication, including the common kitchen spoon, which vary widely in size and shape. In addition, a range of measurement units (millilitre, teaspoon, tablespoon) and their associated abbreviations are used on medicine labels and dosing tools, adding to confusion and errors.12Bpg2

In contrast, effervescent tablets contain a fixed dose per tablet, which eliminates the need for measuring tools and limits dosing errors. Effervescent tablets are also easy to use.

Conclusion

Children average seven to 10 coughs a year, with a considerable impact on their wellbeing.1Apgiii5, Cpgiii1 Given that a cough can last up to four weeks, parents need to seek more effective treatment methods for their children. Evidence for the effectiveness of cough mixtures is not convincing and the combination of ingredients found in some cough mixtures is potentially harmful. 6Apg3, 7A+Bpg175

In addition, dosing errors are common with liquid formulations, which increase the risk side effects in children due to their smaller body size.7Cpg175, 12Apg1 N-acetylcysteine (NAC) is the most commonly used mucolytic and works by making mucus inside the lungs less sticky and easier to cough up.9Apgs216, 11Apg106

It is proven to reduce cough and has good overall safety ratings for children over the age of two. 2Cpg15,5Bpg2 NAC is available as an effervescent tablet, easy to use and convenient to carry around. Each tablet contains a fixed dose of NAC and can be pre-mixed in a bottle of water, limiting the possibility of dosing errors.

References:
1. Shields MD, Bush A, Everard ML, et al. Recommendations for the assessment and management of cough in children. Thorax 2008;63(Suppl III):iii1-iii15.
2. Hanson C. Cough mixtures – an overview. S Afr Pharm J 2016;83(5):14-17.
3. Truter I. Cough. Evidence based pharmacy practice. S Afr Pharm J 2007;20-27.
4. Consolini DM. Cough in children. Merck Manual Consumer Version, 2017. [cited 2017 Feb 22]; Available from: http://www.merckmanuals.com/home/childrenshealthissues/symptomsininfantsandchildren/coughinchildren.
5. Chalumeau M, Duijvestijn YCM. Acetylcysteine and carbocysteine for acute upper and lower respiratory tract infections in paediatric patients without chronic broncho-pulmonary disease. Cochrane Database of Systematic Reviews 2013, Issue 5. Art. No.: CD003124. DOI: 10.1002/14651858.CD003124.pub4.
6. Smith SM, Schroeder K, Fahey T. Over-the-counter (OTC)medications for acute cough in children and adults in community settings. Cochrane Database of Systematic Reviews 2014, Issue 11. Art. No.: CD001831. DOI: 10.1002/14651858.CD001831.pub5.
7. Ryan T, Brewer M, Small L. Over-the-counter cough and cold medication use in young children. Ped Nurs 2008;34(2):174-184.
8. Rogers DF. Mucoactive agents for airway mucus hypersecretory diseases. Resp Care 2007;52(9):1176-1197.
9. Rubin BK. The pharmacologic approach to airway clearance: mucoactive agents. Paed Resp Rev 2006;7S:S215-S219.
10. Payne J. Mucolytics. Patient.info, 2015. [cited 2017 Feb 22]; Available from: http://patient.info/health/mucolytics.
11. Majima Y. Mucoactive medications and airway disease. Mini symposium: mucus. Paed Resp Rev 2002;3:104-109.
12. Yin HS, Parker RM, Sanders LM, et al. Liquid medication errors and dosing tools: a randomized controlled experiment. Paediatrics 2016; 138(4):e20160357.

 

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Professor Keertan Dheda has received several prestigious awards including the 2014 Oppenheimer Award, and has published over 160 peer-reviewed papers and holds 3 patents related to new TB diagnostic or infection control technologies. He serves on the editorial board of the journals PLoS One, the International Journal of Tuberculosis and Lung Disease, American Journal of Respiratory and Critical Medicine, Lancet Respiratory Diseases and Nature Scientific Reports, amongst others. Read his full biography at the University of Cape Town Lung Institute.

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