What is the management approach for pediatric cough in an outpatient department (OPD) setting?

Management of Pediatric Cough in Outpatient Department

For children ≤14 years presenting with cough in the OPD, use a pediatric-specific algorithmic approach that categorizes cough by duration (acute vs. chronic at 4 weeks) and characteristics (wet/productive vs. dry), obtaining chest radiograph and spirometry (when age-appropriate) as first-line investigations, while avoiding empirical treatment approaches unless specific clinical features support a particular diagnosis. 1

Initial Classification by Duration

Acute Cough (<4 weeks)

• Most acute cough in children results from viral upper respiratory tract infections and is self-limiting, typically resolving within 2 weeks 1, 2
• Do NOT use over-the-counter cough and cold medications in children, as they provide no symptomatic relief and pose risks of adverse effects 2, 3
• For children >1 year old, honey is the first-line treatment offering more relief than diphenhydramine or placebo 2
• Avoid codeine-containing medications due to potential serious side effects including respiratory distress 2
• Provide supportive care and educate parents on expected illness duration 3

Chronic Cough (>4 weeks)

• Define chronic cough as daily cough persisting more than 4 weeks in children ≤14 years 1
• Up to 30.8% of children with cough >4 weeks may have serious underlying conditions (bronchiectasis, foreign body, aspiration lung disease, cystic fibrosis) 1
• Common adult causes of chronic cough (GERD, upper airway cough syndrome, asthma) should NOT be presumed common in children 1

Systematic Clinical Assessment

History and Physical Examination

Evaluate for specific cough pointers that indicate underlying disease 1:

Red flags requiring further investigation:

• Hemoptysis 2
• Weight loss or failure to thrive 2
• Dysphagia or feeding difficulties 1
• Persistent focal chest findings 2
• Digital clubbing 1
• Chest wall deformity 1
• Cardiovascular abnormalities 1
• Immune deficiency features 1

Cough quality assessment:

• Wet/productive cough suggests protracted bacterial bronchitis, bronchiectasis, or suppurative lung disease 1, 2
• Dry/non-productive cough suggests asthma, post-infectious cough, or upper airway cough syndrome 1, 2
• Barking/croupy cough suggests tracheal pathology 1
• Paroxysmal cough with post-tussive vomiting suggests pertussis 1

Environmental and Social Factors

• Assess tobacco smoke exposure and advise cessation 2
• Evaluate parental expectations and concerns 2
• Determine impact on child's quality of life and family functioning 1

First-Line Investigations

Mandatory baseline tests for chronic cough:

• Chest radiograph for all children with chronic cough 1, 2
• Spirometry (pre- and post-β2 agonist) when age-appropriate (typically >6 years, sometimes >3 years with trained personnel) 1

Additional tests should NOT be routinely performed (skin prick test, Mantoux, bronchoscopy, chest CT) but individualized based on clinical findings and specific cough pointers 1, 2

Management Algorithm Based on Cough Characteristics

Wet/Productive Cough Without Other Specific Pointers

• Treat with 2-week course of antibiotics targeting common respiratory bacteria (amoxicillin-clavulanate) 2
• If cough persists after 2 weeks of appropriate antibiotics, provide additional 2 weeks of treatment 2
• When chronic wet cough resolves with antibiotics, diagnose as protracted bacterial bronchitis (PBB) 2
• If cough persists despite 4 weeks of antibiotics or recurs, consider bronchoscopy and further investigation for bronchiectasis or other suppurative lung disease 1

Dry/Non-Productive Cough

If asthma suspected (wheeze, exercise intolerance, nocturnal symptoms):

• Administer albuterol and monitor clinical response 2
• Perform spirometry with bronchodilator response testing if age-appropriate 1, 2
• Consider airway hyperresponsiveness testing in children >6 years 1
• Only initiate asthma treatment if other features consistent with asthma are present; avoid empirical treatment 1
• If empirical trial used, define limited duration to confirm or refute diagnosis 1

If post-infectious or upper airway cough syndrome suspected:

• Evaluate for recent respiratory infection history 2
• Assess for rhinorrhea, post-nasal drip, throat clearing 1
• Consider watchful waiting as many resolve spontaneously 1

Non-Specific Cough (Dry Cough, Normal Examination, Normal CXR/Spirometry)

• More likely to resolve without specific treatment 1
• Address contributing factors (tobacco smoke exposure, environmental irritants) 2
• Provide reassurance and education to parents 1
• Consider watchful waiting with scheduled follow-up 1

Special Considerations

Pertussis Evaluation

• Test for Bordetella pertussis when clinically suspected (paroxysmal cough, post-tussive vomiting, inspiratory whoop) 1

Tuberculosis Screening

• Perform Mantoux testing only when clinically indicated by exposure history or endemic region 1

Foreign Body Aspiration

• Maintain high index of suspicion in children with sudden onset cough, unilateral wheeze, or focal findings 1
• Consider urgent bronchoscopy if suspected 2

Follow-Up and Referral Criteria

Arrange follow-up if:

• Symptoms deteriorate or fail to improve after 48 hours of appropriate management 2
• Cough persists beyond 4 weeks without clear diagnosis 1

Consider specialist referral for:

• Failure to respond to appropriate initial management 2
• Recurrent episodes despite treatment 2
• Presence of red flag symptoms (hemoptysis, weight loss, persistent focal findings) 2
• Suspected anatomical abnormality requiring specialized evaluation 2
• Serious underlying disease identified (bronchiectasis, aspiration lung disease, cystic fibrosis) 1

Critical Pitfalls to Avoid

• Never use empirical "adult approach" treating presumed GERD, rhinosinusitis, and asthma without specific supporting features 1
• Do not prescribe over-the-counter cough suppressants or cold medications 2, 3
• Avoid codeine-containing preparations 2
• Do not delay investigation of chronic cough >4 weeks, as serious conditions may be missed 1
• Do not perform routine extensive testing without clinical indication 1
• Recognize that cough quality (wet vs. dry) is diagnostically useful in children, unlike adults 1