What is the recommended treatment for a child with a chronic cough?

Management of Chronic Cough in Children

For children ≤14 years with chronic cough (>4 weeks), base management on whether the cough is wet/productive versus dry, and treat according to the specific etiology rather than using empirical approaches unless specific features of a condition are present. 1

Initial Assessment: Characterize the Cough

Determine if the cough is wet/productive or dry, as this fundamentally changes your diagnostic and treatment pathway. 2

• Assess cough duration: chronic cough is defined as >4 weeks in children 1, 2
• Look for specific "cough pointers" that suggest serious underlying disease: coughing with feeding (aspiration), digital clubbing, hemoptysis, failure to thrive 1, 2
• Identify exacerbating factors, particularly environmental tobacco smoke exposure, and advise cessation 1, 2
• Address parental expectations and specific concerns directly 1, 2

Management Algorithm for Wet/Productive Cough

For chronic wet cough (>4 weeks) without specific cough pointers, prescribe 2 weeks of antibiotics targeting common respiratory bacteria (Streptococcus pneumoniae, Haemophilus influenzae, Moraxella catarrhalis) according to local antibiotic sensitivities. 1

Step-by-step approach:

• Initial treatment: 2 weeks of appropriate antibiotics (amoxicillin is typically first-line at 45 mg/kg/day divided every 12 hours) 1, 3
• If cough resolves: Diagnose as protracted bacterial bronchitis (PBB) 1, 2
• If wet cough persists after 2 weeks: Extend antibiotics for an additional 2 weeks (total 4 weeks) 1, 2
• If wet cough persists after 4 weeks of antibiotics: Proceed to further investigations including flexible bronchoscopy with quantitative cultures and sensitivities, with or without chest CT 1, 2

Important distinction:

• Use the term "microbiologically-based-PBB" (PBB-micro) when lower airway confirmation shows ≥10⁴ cfu/mL of respiratory bacteria, versus "clinically-based-PBB" without such confirmation 1

Management Algorithm for Dry Cough

Do not routinely use empirical treatment for upper airway cough syndrome, gastroesophageal reflux disease, or asthma unless other features consistent with these conditions are present. 1

When asthma features are present (wheeze, exercise intolerance, nocturnal symptoms):

• Consider testing for airway hyperresponsiveness in children >6 years 2
• Trial inhaled bronchodilators and monitor clinical response 2
• If empirical trial is used, define a limited duration to confirm or refute the diagnosis 1, 2

When upper airway cough syndrome features are present:

• Evaluate for rhinosinus conditions 1
• Consider post-nasal drip, particularly following recent respiratory infection 2

First-Line Investigations

Obtain chest radiograph and spirometry as first-line investigations to assess for structural abnormalities and airway reactivity. 2

• Do NOT routinely perform additional tests (skin prick test, Mantoux, bronchoscopy, chest CT) unless individualized based on clinical symptoms and signs 1, 2
• Consider testing for Bordetella pertussis when clinically suspected (post-tussive vomiting, paroxysmal cough, inspiratory whoop) 1, 2

Common Pitfalls to Avoid

Never use over-the-counter cough and cold medications in children, as they lack proven efficacy and carry potential for serious toxicity. 2, 4

• Avoid codeine-containing medications due to risk of respiratory distress 2
• Do not use empirical treatment approaches without specific clinical features supporting the diagnosis 1, 2
• Avoid chest physiotherapy in children with respiratory infections—it is not beneficial 4, 3

Symptomatic Management

For children >1 year with acute cough, honey offers more relief than no treatment, diphenhydramine, or placebo. 2

• Ensure adequate hydration to thin secretions 2, 4
• Use saline nasal drops for nasal congestion 3
• Elevate head of bed to improve breathing during sleep 3
• Avoid honey in children <1 year due to botulism risk 3

When to Escalate Care

Refer for further investigation if the child fails to respond to appropriate initial management or presents with concerning features. 2

• Hemoptysis, weight loss, or persistent focal findings warrant referral 2
• Recurrent episodes despite appropriate treatment require specialized evaluation 2
• Suspected anatomical abnormality needs pulmonology or otolaryngology assessment 2
• Consider urgent bronchoscopy if foreign body is suspected 2