What is the appropriate management for a child with a persistent cough?

Management of Persistent Cough in Children

Base management on identifying the specific etiology of the cough rather than using empirical treatment approaches for presumed upper airway cough syndrome, GERD, or asthma unless clear features of these conditions are present. 1

Initial Classification: Wet vs. Dry Cough

The critical first step is determining whether the cough is wet/productive or dry, as this fundamentally changes your diagnostic and treatment pathway. 1, 2

For Wet/Productive Cough (>4 weeks duration)

Treat with 2 weeks of antibiotics targeting common respiratory bacteria (Streptococcus pneumoniae, Haemophilus influenzae, Moraxella catarrhalis) according to local antibiotic sensitivities. 1, 2

• Amoxicillin dosing for children ≥3 months and <40 kg: 45 mg/kg/day divided every 12 hours or 40 mg/kg/day divided every 8 hours for moderate to severe infections 3
• If cough resolves within 2 weeks: Diagnose as protracted bacterial bronchitis (PBB) 1, 2
• If wet cough persists after 2 weeks: Administer an additional 2-week course of appropriate antibiotics 1, 2
• If wet cough persists after 4 weeks total: Proceed to further investigations including flexible bronchoscopy with quantitative cultures and/or chest CT 1, 2

For Dry/Non-Productive Cough

Evaluate for asthma if associated features are present (wheeze, exercise intolerance, nocturnal symptoms, reversible airway obstruction). 1, 2

• Obtain chest radiograph and spirometry (in children >6 years, sometimes >3 years with trained personnel) as first-line investigations 1, 2
• Consider airway hyperresponsiveness testing if asthma is suspected in children >6 years 1, 2
• Do NOT use empirical inhaled corticosteroids unless other features consistent with asthma are present 1
• If a trial of asthma treatment is initiated, define a specific limited duration (2-4 weeks) to confirm or refute the diagnosis, then discontinue if no response 1

Essential Initial Investigations

Obtain chest radiograph and spirometry (if child >6 years) as first-line tests when structural abnormalities or airway reactivity are suspected. 1, 2

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

Specific Cough Pointers Requiring Further Investigation

If any of the following are present, proceed directly to targeted investigations rather than empirical treatment: 1, 2

• Coughing with feeding (suggests aspiration)
• Digital clubbing (suggests bronchiectasis or chronic lung disease)
• Hemoptysis
• Failure to thrive or weight loss
• Abnormal chest radiograph or spirometry
• Focal chest findings on examination

Universal Management Interventions

Identify and address environmental tobacco smoke exposure and other pollutants, with cessation counseling initiated. 1

• Determine parental and child expectations, address specific concerns about the cough 1
• Educate families that chronic cough causes significant healthcare burden and impairs quality of life, but most cases have identifiable, treatable causes 1

Common Pitfalls to Avoid

• Never use the empirical "asthma-GERD-upper airway cough syndrome" treatment approach common in adults unless specific features of these conditions are present 1
• Avoid over-the-counter cough medications in children <6 years, as they lack proven efficacy and carry safety risks 4
• Do not diagnose "cough-variant asthma" without demonstrating variable airflow obstruction and bronchodilator response on spirometry in older children 1, 5
• Recognize that most non-specific dry coughs in children resolve spontaneously (post-viral) and do not require treatment 1, 2

When to Refer to Pediatric Pulmonology

Consider specialist referral for: 2

• Wet cough persisting after 4 weeks of appropriate antibiotics
• Suspected bronchiectasis, aspiration, or interstitial lung disease
• Failure to respond to appropriate etiology-based treatment
• Recurrent episodes despite appropriate management
• Need for bronchoscopy or advanced imaging interpretation

Age-Specific Considerations

For children <3 months: Maximum dose is 30 mg/kg/day divided every 12 hours due to immature renal function 3

For children >14 years: Transition to adult chronic cough guidelines, though the exact age cutoff lacks strong evidence 1