What is the initial approach to managing cough in pediatric patients?

Initial Approach to Managing Cough in Pediatric Patients

Define the Cough Duration and Classify

For children aged ≤14 years, chronic cough is defined as daily cough persisting for more than 4 weeks, and this timepoint is critical because serious underlying conditions (bronchiectasis, aspiration lung disease, cystic fibrosis, inhaled foreign body) are documented in 18-30% of children with cough exceeding this duration 1.

• Acute cough typically lasts <2 weeks and reflects common upper respiratory viral infections in otherwise healthy children 1
• The 4-week threshold ensures children are not dismissed as having post-viral cough when serious progressive respiratory illness may be present 1

Perform Systematic Clinical Assessment

Obtain a thorough clinical history and physical examination specifically looking for "specific cough pointers" that indicate underlying disease, as the presence of any specific pointer has a sensitivity of 1.0 and positive likelihood ratio of 20 for identifying a cause requiring specific treatment 1.

Critical Specific Cough Pointers to Identify:

• Coughing with feeding (suggests aspiration) 1
• Digital clubbing (indicates chronic suppurative lung disease) 1
• Hemoptysis 1
• Failure to thrive or weight loss 1
• Focal chest findings on examination 1
• Recurrent pneumonia 1

Obtain First-Line Investigations

Chest radiograph and spirometry (when age-appropriate, typically >6 years) should be performed as minimum investigations for any child with chronic cough, as these have infinite positive likelihood ratios when abnormal 2, 1.

• Spirometry can be reliably performed in children >6 years and sometimes in children >3 years with trained pediatric personnel 1
• These tests help exclude structural abnormalities and assess for airway reactivity 2
• Normal results do not rule out disease, requiring clinical correlation 2

Classify Cough as Wet/Productive vs. Dry

The most important divergence point in pediatric cough algorithms is determining whether the cough is wet/productive versus dry, as this fundamentally determines the diagnostic and treatment pathway 2, 1.

For Wet/Productive Cough Without Specific Pointers:

Treat with a 2-week course of antibiotics targeting common respiratory bacteria (Streptococcus pneumoniae, Haemophilus influenzae, Moraxella catarrhalis) for suspected protracted bacterial bronchitis (PBB) 2, 1.

• If cough persists after 2 weeks, administer an additional 2-week course of appropriate antibiotics 2, 1
• When chronic wet cough resolves with antibiotics, the diagnosis of PBB is confirmed 2
• Amoxicillin-clavulanate is commonly used, with pediatric dosing of 45 mg/kg/day divided every 12 hours showing comparable efficacy to every 8-hour dosing with significantly lower diarrhea rates (14% vs 34%) 3

For Wet/Productive Cough With Specific Pointers:

Further investigations including flexible bronchoscopy, chest CT, assessment for aspiration, and evaluation of immunologic competency must be undertaken to assess for underlying disease 1.

For Dry Cough:

Consider asthma if associated symptoms include wheeze, exercise intolerance, nocturnal symptoms, or recurrent episodes relieved by bronchodilator 2, 4.

• Perform spirometry with pre- and post-bronchodilator testing to objectively document airway reactivity and reversible airflow obstruction 4
• Children with chronic dry cough and asthma risk factors may benefit from a short trial of inhaled corticosteroids 2
• If spirometry cannot be performed due to age, an empirical trial of inhaled corticosteroids is reasonable when strong clinical features of asthma are present 4

Use Pediatric-Specific Management Algorithms

High-quality evidence demonstrates that using children-specific cough management protocols improves clinical outcomes, with the CHEST guideline algorithm having the strongest evidence base from randomized controlled trials and cohort studies 1.

• Common etiologies of chronic cough in adults (GERD, upper airway cough syndrome) should not be presumed common in children 1
• Age and clinical setting (country, region) must be considered when evaluating chronic cough 1

Critical Management Principles

Avoid empirical treatment approaches not based on specific findings or suspected diagnoses 2, 1.

• Do not treat for GERD when there are no GI clinical features (recurrent regurgitation, dystonic neck posturing in infants, heartburn/epigastric pain in older children) 1
• Do not use asthma medications unless other evidence of asthma is present 1, 2
• If empirical trial is used, limit to 2-4 weeks with defined endpoints to confirm or refute the diagnosis 5, 4

Identify and eliminate environmental tobacco smoke exposure and other pollutants, as these exacerbate cough regardless of etiology 5, 2.

Assess the impact of cough on the child and family, as chronic cough significantly impairs quality of life comparable to other chronic illnesses (cardiac, diabetes, obesity) 1.

When to Refer

Consider referral to respiratory specialist for children who fail to respond to appropriate initial management, present with concerning symptoms (hemoptysis, weight loss, persistent focal findings), or have recurrent episodes despite appropriate treatment 2.

• In high TB prevalence countries or settings, screen for tuberculosis regardless of cough duration 1
• If chronic cough remains medically unexplained after comprehensive evaluation, consider tic cough (formerly habit cough) when core features of tics are present: suppressibility, distractibility, suggestibility, variability, and premonitory sensation 1