Management of Chronic Cough in Children with Gastroesophageal Reflux Disease (GERD)

Diagnosis and Treatment Approach

• The American College of Chest Physicians recommends against using acid suppressive therapy (PPIs or H2 blockers) solely for chronic cough in children unless there are clear gastrointestinal symptoms of GERD present (Grade 1C recommendation) 1, 2
• If no gastrointestinal symptoms are present, the CHEST guidelines explicitly recommend against using GERD treatments, and instead suggest evaluating for other causes of chronic cough (Grade 1B recommendation) 1, 3
• The American College of Chest Physicians suggests that acid suppressive therapy should not be used solely for chronic cough (Grade 1C recommendation) 1, 2

Lifestyle Modifications and Pharmacologic Therapy

• The American Academy of Pediatrics suggests starting with lifestyle modifications, including dietary changes, feeding modifications, and positioning, for 4-8 weeks before considering pharmacologic therapy 5
• If lifestyle modifications fail, consider pharmacologic therapy with PPI or H2 receptor antagonist for 4-8 weeks maximum 1, 2, 6

Critical Safety Concerns with PPI Use

• The American College of Chest Physicians notes that PPIs carry significant risks in children, including increased risk of lower respiratory tract infections (OR 6.56; 95% CI 1.18-26.25) 2, 8
• The American College of Chest Physicians also notes that PPIs may increase the risk of community-acquired pneumonia, gastroenteritis, and candidemia 7
• Long-term use of PPIs may lead to vitamin B12 deficiency and bone fractures 2, 7

Important Clinical Pitfalls to Avoid

• The American College of Chest Physicians warns against using PPIs for isolated chronic cough without GI symptoms, as this may cause more harm than benefit 1, 2, 8
• The American College of Chest Physicians also warns against continuing acid suppression beyond 4-8 weeks without reevaluation, as PPIs should not be used longer than this timeframe without further diagnostic workup 1, 6, 7

Referral to Pediatric Gastroenterology

• The American Academy of Pediatrics suggests referring children to pediatric gastroenterology if symptoms persist despite 4-8 weeks of optimal medical therapy, or if warning signs are present 1, 5
• The American College of Chest Physicians also suggests referring children for diagnostic testing (endoscopy, pH monitoring) or consideration of surgical intervention 1, 5, 6