What is the assessment and management plan for a 2-year-old presenting with a cough?

Assessment and Management of Cough in a 2-Year-Old Child

For a 2-year-old child with cough, a systematic evaluation should be performed to determine the cause, with treatment directed at the underlying etiology rather than using over-the-counter cough suppressants, which can cause significant morbidity and mortality in young children. 1

Initial Assessment

History

• Duration of cough (acute <3 weeks, chronic >4 weeks)
• Character of cough (wet/productive vs. dry)
• Associated symptoms:
  • Fever
  • Wheeze
  • Shortness of breath
  • Feeding difficulties
  • Sleep disturbance

Red Flags Requiring Urgent Evaluation 2

• Digital clubbing
• Failure to thrive
• Hemoptysis
• Recurrent pneumonia
• Feeding difficulties
• Abnormal lung examination
• Family history of chronic lung disease

Physical Examination

• Vital signs including oxygen saturation (target >92%) 2
• Growth parameters
• Complete respiratory examination
• ENT examination for postnasal drip
• Signs of atopy

Diagnostic Approach

Initial Investigations

• Chest radiograph (recommended as minimum investigation) 1, 2
• Spirometry if age-appropriate (typically not feasible in a 2-year-old) 1

Additional Tests (Based on Clinical Suspicion)

• Pertussis testing if clinically suspected 1
• Further investigations should be individualized based on clinical findings 1

Management Algorithm

1. Acute Cough (<3 weeks)

• Likely viral upper respiratory infection
• Management:
  • Supportive care
  • Adequate hydration
  • Honey (10ml mixed with warm water or milk) up to three times daily (safe and effective for children >1 year) 2
  • Avoid over-the-counter cough medications including dextromethorphan due to potential harm and minimal efficacy 1, 3, 4

2. Chronic Wet/Productive Cough (>4 weeks)

• Consider protracted bacterial bronchitis (PBB)
• Management:
  • Appropriate antibiotics for 2 weeks targeting common respiratory bacteria 1, 2
  • If cough persists after 2 weeks of antibiotics, extend antibiotic treatment for additional 2 weeks 1
  • If cough persists after 4 weeks of appropriate antibiotics, further investigations needed (e.g., flexible bronchoscopy, chest CT) 1, 2

3. Chronic Dry Cough with Asthma Risk Factors

• Consider cough variant asthma
• Management:
  • Trial of inhaled corticosteroids (beclomethasone 400 μg/day or equivalent) for 2-4 weeks 1, 2
  • Short-acting beta-agonist as needed for symptom relief 2
  • Re-evaluate in 2-4 weeks 1, 2
  • If no improvement, discontinue and consider alternative diagnoses 1

4. Cough with GERD Symptoms

• Only treat for GERD if GI symptoms are present
• Do not use GERD treatments when there are no GI clinical features 1, 2

Follow-up and Monitoring

• Re-evaluate after 2 weeks of treatment to assess response 2
• If cough persists despite appropriate treatment, consider referral to specialist 2
• For children on inhaled corticosteroids, re-evaluate in 2-4 weeks 1

Important Caveats

1. Never use cough suppressants or other over-the-counter cough medicines in young children due to risk of significant morbidity and mortality 1, 3, 4

2. Antibiotics should only be used for wet/productive cough suggestive of bacterial infection, not for routine management of cough 1, 2

3. Empiric treatment for GERD without specific GI symptoms is not recommended 1, 2

4. If specific cough pointers emerge during treatment or if cough recurs despite appropriate treatment, further evaluation is necessary 2

5. Most children with nonspecific cough do not have asthma, so inhaled corticosteroids should only be used as a time-limited trial when asthma is suspected 1