Management of Pediatric Patients with Chronic Cough

Initial Assessment

The American College of Chest Physicians recommends determining if the cough is wet/productive or dry, as this significantly influences the diagnostic approach, in pediatric patients with a 3-month history of cough 1, 2
Initial investigations should include chest radiograph and spirometry (if age appropriate), as recommended by the American Thoracic Society 4, 5
Evaluate for specific "cough pointers" that suggest underlying disease, including digital clubbing, coughing with feeding, or abnormal chest examination, as suggested by the American College of Chest Physicians 6, 7
Consider age and clinical setting (country and region) when evaluating chronic cough in children, according to the American Academy of Pediatrics 1

The American College of Chest Physicians recommends considering protracted bacterial bronchitis (PBB) if cough has persisted >4 weeks without other specific pointers, and treating with appropriate antibiotics (typically amoxicillin) for 2 weeks 6, 5
For children with chronic productive purulent cough, always investigate to document presence or absence of bronchiectasis and identify underlying treatable causes, as recommended by the American Thoracic Society 4

Avoid empiric treatment for asthma unless other features consistent with asthma are present, as recommended by the American College of Chest Physicians 2, 7
If risk factors for asthma exist, consider a short trial (2-4 weeks) of beclomethasone 400 μg/day or equivalent budesonide dose, according to the National Asthma Education and Prevention Program 4, 7
Do not use treatments for gastroesophageal reflux disease (GERD) when there are no GI clinical features of reflux, as recommended by the American College of Chest Physicians 2, 8
If GERD is suspected based on GI symptoms, treat according to GERD-specific guidelines for 4-8 weeks and reevaluate response, as suggested by the North American Society for Pediatric Gastroenterology 8, 9

Do not presume that common causes of chronic cough in adults are common causes in children, as stated by the American Academy of Pediatrics 1
Avoid over-the-counter cough and cold medications, especially in children under 2 years, due to lack of efficacy and potential serious side effects, as recommended by the American Academy of Pediatrics 3, 7
Address environmental factors such as tobacco smoke exposure, as suggested by the American Thoracic Society 4, 3

If cough persists despite appropriate initial management, consider further evaluation, as recommended by the American College of Chest Physicians 5
If specific cough pointers emerge during follow-up, consider further evaluation, according to the American Thoracic Society 4
For children with chronic wet or productive cough with specific cough pointers, consider further evaluation, as suggested by the American College of Chest Physicians 6

All children with chronic cough should be reevaluated within 2-4 weeks, as recommended by the American Thoracic Society 4, 7
For children with nonspecific cough, monitor for emergence of specific etiologic pointers, according to the American College of Chest Physicians 4
For children diagnosed with somatic cough disorder, consider non-pharmacological trials of hypnosis, suggestion therapy, or combinations of reassurance, counseling, or referral to a psychologist/psychiatrist, as suggested by the American College of Chest Physicians 9

Using adult cough management approaches in pediatric patients, as stated by the American Thoracic Society 4
Empirical treatment aimed at upper airway cough syndrome, GERD, or asthma without other features consistent with these conditions, as recommended by the American College of Chest Physicians 1
Prolonged use of medications without reevaluation, as suggested by the American Thoracic Society 4, 3