What are the guidelines for managing a pediatric patient with a 3-month history of cough?

Management of Pediatric Patients with 3-Month History of Cough

For pediatric patients with a 3-month history of cough, a systematic approach based on cough characteristics (wet vs. dry) and specific clinical pointers should guide evaluation and management, rather than empirical treatment approaches. 1

Initial Assessment

• Determine if the cough is wet/productive or dry, as this significantly influences the diagnostic approach 2
• Obtain chest radiograph and spirometry (if age appropriate) as minimum initial investigations 1, 3
• Evaluate for specific "cough pointers" that suggest underlying disease, including digital clubbing, coughing with feeding, or abnormal chest examination 1, 4
• Consider age and clinical setting (country and region) when evaluating chronic cough in children 1

Management Based on Cough Characteristics

For Wet/Productive Cough:

• Consider protracted bacterial bronchitis (PBB) if cough has persisted >4 weeks without other specific pointers 1, 3
• For PBB, treat with appropriate antibiotics (typically amoxicillin) for 2 weeks 1, 5
• If specific cough pointers are present (e.g., digital clubbing, coughing with feeding), conduct further investigations including flexible bronchoscopy, chest CT, assessment for aspiration, and/or evaluation of immunologic competency 1
• For children with chronic productive purulent cough, always investigate to document presence or absence of bronchiectasis and identify underlying treatable causes 1

For Dry/Non-productive Cough:

• Avoid empiric treatment for asthma unless other features consistent with asthma are present 1, 4
• If risk factors for asthma exist, consider a short trial (2-4 weeks) of beclomethasone 400 μg/day or equivalent budesonide dose 1, 4
• Do not use treatments for gastroesophageal reflux disease (GERD) when there are no GI clinical features of reflux 1
• If GERD is suspected based on GI symptoms, treat according to GERD-specific guidelines for 4-8 weeks and reevaluate response 1

Important Considerations

• Do not presume that common causes of chronic cough in adults are common causes in children 1
• Avoid over-the-counter cough and cold medications, especially in children under 2 years, due to lack of efficacy and potential serious side effects 2, 4
• Address environmental factors such as tobacco smoke exposure 1, 2
• If medications are used, follow up and discontinue therapy if there is no effect within the expected timeframe 1, 2

When to Consider Further Evaluation

• If cough persists despite appropriate initial management 3
• If specific cough pointers emerge during follow-up 1
• For children with chronic wet or productive cough with specific cough pointers 1
• If initial treatment fails, particularly in cases involving airway hyperreactivity 6

Follow-up Recommendations

• All children with chronic cough should be reevaluated within 2-4 weeks 1, 4
• For children with nonspecific cough, monitor for emergence of specific etiologic pointers 1
• For children diagnosed with somatic cough disorder (previously referred to as psychogenic cough), consider non-pharmacological trials of hypnosis, suggestion therapy, or combinations of reassurance, counseling, or referral to a psychologist/psychiatrist 1

Common Pitfalls to Avoid

• Using adult cough management approaches in pediatric patients 1
• Empirical treatment aimed at upper airway cough syndrome, GERD, or asthma without other features consistent with these conditions 1
• Overdiagnosis of asthma in children with chronic non-specific cough 7
• Prolonged use of medications without reevaluation 1, 2