Initial Approach to Managing Cough in Pediatric Patients
For children with cough, a systematic approach using pediatric-specific cough management protocols is recommended, with treatment based on cough characteristics and clinical history rather than empirical approaches. 1
Assessment and Classification
Initial Evaluation
- Determine cough duration:
- Acute: <2 weeks (typically viral respiratory infections)
- Prolonged acute: 2-4 weeks
- Chronic: >4 weeks
Key Cough Characteristics
- Wet/productive vs. dry cough - critical distinction that guides management 1
- Quality of cough (barking, staccato, paroxysmal, honking)
- Timing (nocturnal, with feeding, exercise-induced)
- Associated symptoms (fever, weight loss, night sweats)
Specific Cough Pointers
Look for these specific cough pointers that suggest underlying disease 1:
- Chest pain
- Digital clubbing
- Failure to thrive
- Hemoptysis
- Hypoxia/cyanosis
- Immunodeficiency
- Feeding difficulties
- Recurrent pneumonia
- Abnormal voice/cry
- Wheeze/stridor
Basic Investigations
For children with chronic cough (>4 weeks), the following investigations are recommended 1:
- Chest radiograph - recommended for all children with chronic cough (Grade 1B) 1, 2
- Spirometry (when age appropriate, typically >6 years) with pre and post β2-agonist testing (Grade 1B) 1
Additional investigations should be individualized based on clinical findings and not performed routinely 1.
Management Algorithm
1. For Non-Specific Cough (Dry Cough with No Specific Pointers)
- Watch, wait, and review approach 1
- Usually represents post-viral cough or acute bronchitis
- Consider and evaluate:
- Foreign body inhalation
- Asthma
- Upper airway disorders
- Medication side effects
- Pertussis
- Mycoplasma
2. For Specific Cough (With Pointers to Underlying Disease)
- Investigate and treat according to suspected etiology
- For wet/productive cough >4 weeks without specific pointers:
- Consider protracted bacterial bronchitis (PBB)
- Prescribe 2 weeks of antibiotics targeting common respiratory bacteria (Streptococcus pneumoniae, Haemophilus influenzae, Moraxella catarrhalis) (Grade 1A) 1, 2
- If cough resolves within 2 weeks of antibiotics, diagnose as PBB (Grade 1C) 1
- If cough persists, extend antibiotics for additional 2 weeks 2
3. For Suspected Asthma
- In children >6 years, consider airway hyperresponsiveness testing (Grade 2C) 1
- For younger children where objective testing is difficult, a time-limited trial of asthma medication may be appropriate 1
- Important: Do not use empirical trials for asthma unless other features consistent with asthma are present 1
Follow-up and Monitoring
- Scheduled follow-up within 2-4 weeks for all children with chronic cough 1, 2
- If using empirical treatment trials, these should be of defined limited duration to confirm or refute the hypothesized diagnosis 1
- If cough persists despite 4 weeks of appropriate antibiotics for wet cough, refer to a pediatric pulmonologist 2
Common Pitfalls to Avoid
Using adult cough management approaches in children - pediatric cough etiologies differ significantly from adults 1
Empirical treatment without supporting features - avoid empirical treatment for upper airway cough syndrome, gastroesophageal reflux, or asthma unless other features of these conditions are present 1
Inadequate antibiotic duration for wet cough - some children require up to 4 weeks of treatment for complete resolution 2
Missing serious underlying conditions - 18% of children with chronic cough in a multicenter study had serious underlying respiratory illness (bronchiectasis, aspiration lung disease, cystic fibrosis) 1
Neglecting environmental factors - tobacco smoke exposure should be determined and cessation advised 1
Overlooking parental concerns - address specific concerns of parents and, when appropriate, the child 1
By following this systematic approach to pediatric cough management, clinicians can effectively identify and treat the underlying causes, improving outcomes and reducing unnecessary treatments.