Assessment and Management of Chronic Cough in Infants

Initial Assessment and Diagnosis

The American College of Chest Physicians recommends that a pediatric-specific systematic algorithm be used to assess and manage chronic cough in infants, based on whether the cough is wet/productive versus dry, and to obtain a chest radiograph and assess for specific cough pointers indicating serious underlying disease 1, 2, 3
Chronic cough in infants is defined as a daily cough lasting ≥4 weeks, and its impact on both the infant and family should be assessed, as it can significantly impair quality of life and may indicate serious underlying disease such as bronchiectasis or foreign body aspiration 1, 3, 4
The single most important clinical distinction is determining whether the cough is wet/productive versus dry, as this fundamentally changes the diagnostic and treatment pathway 2, 3, 5

Specific cough pointers that indicate serious underlying disease include coughing with feeding, digital clubbing, failure to thrive or poor weight gain, focal chest findings on examination, hemoptysis, and cardiovascular abnormalities 3, 5, 6
The presence of any specific cough pointer indicates the cough is "specific" and requires investigation beyond initial management 3

For wet/productive cough without specific pointers, the most likely diagnosis is protracted bacterial bronchitis (PBB), and treatment should include a 2-week course of antibiotics targeting common respiratory bacteria 5, 6
Amoxicillin is the first-line antibiotic choice for children under 5 years, and the dose should be adjusted based on the child's age and weight 6
For dry/non-productive cough without specific pointers, a "watch, wait, and review" strategy should be implemented, and empirical treatment for asthma or GERD should be avoided unless other features of these conditions are present 1, 2, 3, 6

A chest radiograph should be obtained in all children with chronic cough, as it is highly specific for identifying structural abnormalities, foreign bodies, pneumonia, or bronchiectasis 1, 2, 3
Spirometry is not appropriate for children under 6 years, and airway hyperresponsiveness testing is only suggested for children >6 years with suspected asthma 1, 2, 4

Environmental pollutants such as tobacco smoke should be eliminated, and adequate hydration should be ensured to help thin secretions 3, 5, 6
Parental expectations and concerns should be assessed, and education should be provided about the natural course of post-viral cough 3, 5, 6

Re-evaluation should be performed if symptoms deteriorate or fail to improve after 48 hours of appropriate management, and continued re-evaluation should be performed until a diagnosis is established and cough resolves 3, 6
Referral to pediatric pulmonology should be considered if cough fails to respond to appropriate initial management, specific pointers suggest serious underlying disease, or recurrent episodes occur despite appropriate treatment 5, 6