What is the evaluation and treatment plan for a four-year-old presenting with a dry, hacking cough?

Management of Dry, Hacking Cough in a Four-Year-Old

For a four-year-old presenting with a dry, hacking cough, I recommend using a systematic pediatric-specific cough management algorithm based on cough characteristics, with initial evaluation including chest radiograph to rule out serious underlying conditions. 1

Initial Evaluation

• Determine cough duration - chronic cough is defined as daily cough lasting at least 4 weeks in children ≤14 years 1
• Assess cough characteristics - dry/hacking vs. wet/productive 1
• Look for specific cough pointers such as:
  • Associated symptoms (wheezing, exercise intolerance, nocturnal symptoms) 2
  • Digital clubbing, feeding difficulties, or other signs of underlying disease 1
• Obtain a chest radiograph as a first-line investigation 1
• Consider spirometry if the child is >6 years old (not applicable for a 4-year-old) 1

Management Algorithm for Dry, Hacking Cough

If No Specific Cough Pointers (Non-Specific Cough)

• Watch, wait, and review approach - likely post-viral cough or acute bronchitis 1
• Consider and examine for:
  • Foreign body inhalation
  • Asthma or asthma-like symptoms
  • Upper airway disorders
  • Medication adverse effects
  • Pertussis
  • Mycoplasma infection 1

If Asthma is Suspected

• Look for associated symptoms of wheeze, exercise intolerance, or nocturnal symptoms 2, 3
• Consider a trial of bronchodilator therapy 2, 4
• If using inhaled corticosteroids (ICS), reassess in 2-4 weeks and discontinue if no improvement and no other features of asthma 1
• Avoid empirical treatment for asthma unless other features consistent with the condition are present 1

Important Considerations

• Do NOT use over-the-counter cough and cold medications in children under 6 years due to lack of efficacy and risk of serious adverse effects 5, 6
• For children over 1 year, honey can be considered as a first-line therapy for symptomatic relief of acute dry cough 6
• Avoid codeine-containing medications due to risk of respiratory depression 6
• Address environmental factors like tobacco smoke exposure 2, 6

When to Consider Additional Testing

• If cough persists beyond 4 weeks despite appropriate management 1
• If specific cough pointers develop (digital clubbing, hemoptysis, etc.) 1
• If abnormalities are found on chest radiograph 1
• Consider tests for Bordetella pertussis if clinically suspected (paroxysmal cough, post-tussive vomiting, inspiratory whoop) 1

When to Refer to a Specialist

• If cough persists after 4 weeks of appropriate management 1
• If there are concerning symptoms such as hemoptysis, weight loss, or persistent focal findings 2
• If there are recurrent episodes of cough despite appropriate treatment 2

Follow-up Recommendations

• Review within 2-4 weeks if symptoms persist 1, 6
• Discontinue any empirical medications if no effect is observed 6
• Re-evaluate if cough characteristics change (e.g., dry cough becomes wet/productive) 1

Warning Signs Requiring Immediate Medical Attention

• Respiratory distress (increased respiratory rate, retractions, grunting) 5, 6
• Cyanosis or oxygen saturation <92% if measured 5
• Poor feeding or signs of dehydration 5
• Persistent high fever 5