What is the appropriate initial evaluation and treatment for an 8-year-old child with a chronic cough suspected to be due to allergies?

Initial Evaluation and Treatment for an 8-Year-Old with Chronic Cough Suspected to be Due to Allergies

For an 8-year-old child with a chronic cough of 4 weeks duration suspected to be due to allergies, a systematic evaluation should be performed first, as empirical treatment for allergies without supportive evidence is not recommended. 1

Initial Assessment

Step 1: Determine Cough Characteristics

• Cough quality: Wet/productive vs. dry cough
• Timing: Day, night, or both
• Triggers: Exercise, cold air, feeding, seasonal patterns
• Associated symptoms: Wheezing, shortness of breath, nasal congestion, postnasal drip

Step 2: Essential Initial Investigations

• Chest radiograph - mandatory first-line investigation 1
• Spirometry (pre- and post-bronchodilator) - can be reliably performed in children aged >6 years 1

Diagnostic Algorithm Based on Cough Characteristics

If Dry Cough (Non-specific cough without specific pointers):

1. Watch, wait and review - may be post-viral cough 1
2. Consider asthma evaluation if:
   • History of wheezing
   • Family history of atopy/asthma
   • Symptoms worsen with exercise or cold air
   • Consider airway hyperresponsiveness testing 1

If Wet/Productive Cough:

1. Consider protracted bacterial bronchitis (PBB) - most common cause of chronic wet cough in children 1
2. Consider 2-week course of appropriate antibiotics 1
3. If cough persists after 4 weeks of antibiotics, further investigations needed 1

Important Considerations for Suspected Allergic Etiology

When to Consider Allergies:

• Seasonal patterns to symptoms
• Associated allergic rhinitis symptoms (sneezing, itchy/watery eyes, nasal congestion)
• Family history of atopy
• Improvement in symptoms when away from potential allergens

Caution with Empiric Treatment:

The CHEST guidelines specifically recommend against empirical treatment approaches unless other features consistent with the suspected condition are present 1.

GERD Considerations

• Do NOT use treatments for GERD when there are no clinical features of gastroesophageal reflux 1
• GERD is not commonly identified as the cause of isolated chronic cough in children 1
• Acid suppressive therapy should not be used solely for chronic cough 1

Asthma Considerations

• If asthma is suspected based on history and examination:
  • For children aged 6-14 years: Montelukast 5mg chewable tablet once daily in the evening may be considered 2
  • Response should be evaluated after 2-4 weeks 1
  • If no improvement, discontinue treatment 1

Common Pitfalls to Avoid

1. Treating empirically without proper evaluation - This can delay diagnosis of serious underlying conditions 1
2. Assuming adult causes apply to children - Common etiologies of chronic cough in adults are not the same as in children 1
3. Prolonged use of medications without benefit - If no improvement after 2-4 weeks, reevaluate diagnosis 1
4. Missing serious underlying conditions - Up to 18% of children with chronic cough may have serious underlying respiratory conditions 1

When to Refer to a Specialist

• Abnormal chest radiograph or spirometry
• Persistent wet cough despite appropriate antibiotic therapy
• Digital clubbing or other signs of chronic lung disease
• Failure to thrive or systemic symptoms
• Cough persisting beyond 8-12 weeks despite appropriate management

Remember that chronic cough in children should be approached systematically with appropriate investigations before initiating treatment, as early diagnosis and appropriate management lead to better outcomes and improved quality of life.