Management of Persistent Cough in Children

Initial Assessment and Classification

The American Thoracic Society recommends determining the cough characteristics systematically to differentiate between wet/productive cough, which suggests protracted bacterial bronchitis, bronchiectasis, or chronic suppurative lung disease, and dry/non-productive cough, which may represent post-viral cough, asthma, or non-specific cough 2
A wet/productive cough requires different management than a dry cough, and its presence should prompt further investigation for underlying conditions such as protracted bacterial bronchitis or bronchiectasis 2
The presence of specific "cough pointers" such as coughing with feeding, digital clubbing, or hemoptysis indicates serious underlying disease and requires prompt evaluation and treatment 1, 2, 4, 5

The American College of Chest Physicians recommends obtaining a chest radiograph and spirometry for all children with chronic cough to guide further workup and treatment 1, 2
These tests are highly specific, and abnormalities definitively indicate underlying disease, although normal results do not exclude disease 2

For wet/productive cough without specific pointers, prescribe a 2-week course of antibiotics targeting common respiratory bacteria, as this likely represents protracted bacterial bronchitis 3, 4
If cough persists after 2 weeks, extend antibiotics for an additional 2 weeks, and if cough persists after 4 weeks, proceed to further investigations including consideration of bronchoscopy, CT chest, and referral to pediatric pulmonology 1, 3, 4
For dry/non-productive cough without specific pointers, adopt a "watch, wait, and review" approach initially, as this is most commonly post-viral cough or acute bronchitis that resolves spontaneously 2
Do not empirically treat for asthma unless other features consistent with asthma are present, and review in 2-4 weeks to assess for resolution or development of specific pointers 1, 2

Avoid empirical treatment approaches, and do not use trials of medications for upper airway cough syndrome, gastroesophageal reflux, or asthma unless specific clinical features support these diagnoses 1
If an empirical trial is necessary, limit it to a defined duration to confirm or refute the diagnosis, then stop if ineffective 1
Do not routinely perform additional tests such as skin prick testing, Mantoux testing, bronchoscopy, or chest CT unless individualized based on clinical findings and specific pointers 1

Identify and eliminate tobacco smoke exposure, which is a major contributor to chronic cough in children, and ensure adequate hydration to help thin secretions and facilitate clearance 2, 3, 4
Do not use over-the-counter cough medications in children, as they lack proven efficacy and carry risk of serious adverse effects 5