Consider reversible causes and treat if appropriate:

• Infection
• Asthma
• Gastro-oesophageal reflux
• Aspiration
• Malignant bronchial obstruction
• Heart failure
• Epileptic seizure activity
• Neuro-degenerative disorders
• Drug induced (e.g. ACE inhibitors)/ treatment related (e.g total body irradiation)

Management

General measures

• Keep child as upright as possible
• Raise head of bed: Use blocks under head end of cot/bed or pillows
• Consider physiotherapy ± suction
• Consider trial of humidified air/oxygen

Medication

Cough suppressants

Simple linctus

Form

Linctus : paediatric preparation (0.625% citric acid monohydrate); adult preparation (2.5% citric acid monohydrate)

Dose (oral)

1 month -12yr: paediatric preparation 5-10mL t.d.s.- q.d.s.
>12yr: adult preparation 5-10mL t.d.s.-q.d.s.

Licence: licensed for children and adults (appropriate preparation).

Morphine linctus

Form

Solution: 10mg in 5mL

Dose (oral)

30-50% of starting dose for analgesia (see pain section)

Bronchodilators

Cough can be a manifestation of hyper-reactive airways/ asthma and a trial of nebulised salbutamol/ ipratropium may be helpful

Ipratropium

May be helpful if bronchospasm is present

Nebulised solution: 250µg in 1mL, 500 µg in 2mL

Dose (nebulised)

Child less than 1 year: 62.5µg 3 to 4 times daily,
Child 1-5 years: 125-250µg 3 to 4 times daily,
Child 5-12 years: 250-500µg 3 to 4 times daily,
Child over 12 years: 500µg 3 to 4 times daily.

Salbutamol

May be helpful if bronchospasm is present.

Aerosol Inhalation

Child 1 month-18years: 100-200µg (1-2 puffs) for persistent symptoms up to four times a day.

Nebulised solution: (2.5mg in 2.5mL, 5mg in 2.5mL, 5mg in 1mL)

Neonate: 1.25-2.5mg up to four times daily,
Child 1 month-18years: 2.5-5 mg up to four times daily.

N.B. Salbutamol may cause a tremor and/or if over-used.

Mucolytics

May be helpful if secretions are thick.

Normal saline

Dose (nebulised)

2.5-5mL

May induce cough reflex in some cases.

Carbocisteine

Form

Liquid 125mg in 5mL

Dose (oral)

2-5yr: 62.5-125mg q.d.s.
6-12 yr: 250mg t.d.s.
>12 yr: 750mg t.d.s. initially, reducing to 1.5g/day in divided doses.

Use primarily in children with Cystic Fibrosis.

Acetylcysteine

Form

Granules: 100mg, 200mg sachets. Named patient basis only.

Dose (oral)

1 month - 2yr: 100-200mg t.d.s.
2-12yr: 200mg t.d.s.
12-18 yr: 200-400mg t.d.s.

Used primarily in children with Cystic Fibrosis. Licence: not licensed in children for this use.

Dornase alfa

Form

Nebulised solution: 1,000 units in 1mL as 2.5mL vial

Dose (nebulised)

Not for children < 5yr.
>5yr: 2.5mL o.d., or b.d. in infective exacerbations

Used primarily in children with Cystic Fibrosis. Licence: licensed for use in children >5yr.

Excessive secretions:

See section on noisy breathing.