What is the treatment for persistent cough in children lasting over a month?

Treatment of Persistent Cough in Children Lasting Over One Month

For children with chronic wet or productive cough lasting more than 4 weeks without specific disease pointers, a 2-week course of antibiotics targeting common respiratory bacteria is the recommended first-line treatment. 1

Initial Assessment

When evaluating a child with persistent cough (>4 weeks):

1. Classify the cough type:

   • Wet/productive vs. dry cough
   • Presence of specific cough pointers (e.g., digital clubbing, feeding difficulties, hemoptysis)

2. Assess impact:

   • Determine effect on child and family quality of life 1
   • Evaluate severity and pattern (day/night, exercise-induced)

Treatment Algorithm Based on Cough Type

For Wet/Productive Cough

1. First-line treatment:

   • Prescribe antibiotics targeting common respiratory bacteria (Streptococcus pneumoniae, Haemophilus influenzae, Moraxella catarrhalis) for 2 weeks 1
   • Amoxicillin is the preferred first-line agent for children:
     • For children <40kg: 45 mg/kg/day divided every 12 hours or 40 mg/kg/day divided every 8 hours 2

2. If cough persists after initial 2-week antibiotic course:

   • Continue with an additional 2-week course of appropriate antibiotics 1
   • Consider alternative antibiotics if no response to first-line treatment

3. If cough persists after 4 weeks of appropriate antibiotics:

   • Further investigations are warranted (e.g., flexible bronchoscopy with quantitative cultures, chest CT) 1
   • Referral to a pediatric pulmonologist is recommended 3

For Dry Cough

1. If asthma is suspected:

   • Consider a 2-4 week trial of inhaled corticosteroids (400 μg/day of beclomethasone equivalent) 3
   • Re-evaluate in 2-4 weeks and discontinue if no improvement

2. If GERD is suspected:

   • Only treat for GERD if GI symptoms are present (regurgitation, dystonic neck posturing in infants, heartburn/epigastric pain in older children) 1
   • Do not use acid suppressive therapy solely for chronic cough 1
   • If treating GERD, follow evidence-based GERD-specific guidelines with 4-8 week treatment course 1

Special Considerations

Protracted Bacterial Bronchitis (PBB)

• Diagnosis of PBB can be made if:
  • Chronic wet cough is present
  • Cough resolves within 2 weeks of appropriate antibiotic treatment 1
  • No specific cough pointers suggesting other diagnoses

Avoiding Ineffective Treatments

• Do not use:
  • Over-the-counter cough medications (minimal efficacy, potential harm) 3
  • Acid suppressive therapy for cough without GI symptoms of GERD 1
  • Prolonged courses of inhaled corticosteroids without evidence of asthma 3

When to Refer to a Specialist

• Cough persists despite 4 weeks of appropriate antibiotics 1
• Presence of specific cough pointers (digital clubbing, feeding difficulties, hemoptysis)
• Recurrent episodes of chronic cough
• Suspected serious underlying condition (bronchiectasis, immunodeficiency)

Common Pitfalls to Avoid

1. Misdiagnosing or overdiagnosing asthma:

   • Not all chronic cough in children is asthma
   • Set time limits for therapeutic trials (2-4 weeks) 3

2. Inadequate antibiotic duration:

   • For wet cough due to PBB, a full 2-week course is necessary
   • May need extension to 4 weeks in some cases 1

3. Treating GERD without GI symptoms:

   • GERD is not commonly identified as the cause of pediatric cough 1
   • Avoid empiric treatment for GERD when no GI symptoms are present

4. Dismissing chronic cough as "just post-viral":

   • Chronic cough may indicate serious underlying conditions in 18% of children 1
   • Early diagnosis and treatment results in less damage

By following this structured approach based on cough characteristics, clinicians can effectively manage persistent cough in children while minimizing unnecessary treatments and identifying those who require further evaluation.