Rational Management of Pediatric Cough and Medication Safety: Evidence-Based Review

Abstract

Acute cough represents India's commonest pediatric presentation accounting for 30-40% of outpatient visits and 15-20% of pediatric emergency presentations. While typically arising from self-limiting viral upper respiratory infections that resolve within 2-4 weeks, it nonetheless prompts widespread Over The Counter (OTC) syrup use despite clear guideline recommendations favoring supportive care. Recent DiEthylene Glycol (DEG) contamination in Indian pediatric medications flagged by World Health Organization (WHO) Medical Product Alert N°5/2025 caused 21 documented child deaths from three implicated syrups (Coldrif, Rednex, Shape), highlighting critical pharmacovigilance gaps. This comprehensive narrative evidence synthesis conducted across PubMed, Cochrane CENTRAL, Embase, and Google Scholar (January 2010-October 31, 2025) included high quality systematic reviews, Randomised Controlled Trials (RCTs), and guidelines for children < 18 years (n=40 sources) with quality assessment via A Measurement Tool to Assess Systematic Reviews 2 (AMSTAR-2) (high-quality threshold) and AGREE-II (≥65% domain scores). British Thoracic Society (BTS) and Indian Academy of Pediatrics (IAP) guidelines classify acute cough (<4 weeks) requiring supportive measures versus chronic cough (≥4 weeks) needing etiology specific therapy. Cochrane reviews confirm OTC antitussives, antihistamines, expectorants lack benefit over placebo (SMD -0.06 to -0.10) despite higher Adverse Events (AEs) (RR 1.45), while honey reduces severity (SMD -0.32) in children > 1 year. Ministry of Health prohibits syrups < 2 years post-DEG deaths; recent Indian data show 78.3% antibiotic overuse despite 92% viral etiology. Indian pediatricians must classify wet/dry cough, avoid routine antibiotics, OTC in acute cases, trial antibiotics with Tuberculosis (TB) screening for chronic wet cough, and ensure Pharmacovigilance Programme of India (PvPI) reporting.