What is the appropriate management for cough in children?

Management of Cough in Children

For children with cough, use a systematic, algorithm-based approach that prioritizes cough duration (acute vs. chronic at 4 weeks), cough characteristics (wet vs. dry), and specific clinical pointers rather than empirical treatment of presumed adult diagnoses like asthma, GERD, or upper airway cough syndrome. 1

Define the Cough Duration and Type

• Chronic cough is defined as daily cough lasting more than 4 weeks in children aged ≤14 years 1, 2
• Acute cough (<4 weeks) is typically self-limited viral illness and requires supportive care only 2, 3
• Determining whether the cough is wet/productive versus dry is the critical first branching point in your diagnostic algorithm 1, 2

Initial Investigations for Chronic Cough

Obtain a chest radiograph for all children with chronic cough 1, 2

Obtain spirometry (pre- and post-β2 agonist) when age-appropriate (typically >6 years) 1

• Do NOT routinely perform additional tests like skin prick testing, Mantoux, bronchoscopy, or chest CT unless specifically indicated by clinical findings 1, 2
• Most young children cannot generate reliable spirometry data until age 6 years 1

Management Algorithm for Wet/Productive Cough

For chronic wet cough (>4 weeks) without specific red flag pointers, prescribe a 2-week course of antibiotics targeting common respiratory bacteria (amoxicillin-clavulanate is appropriate) 2, 3

If cough resolves after 2 weeks of antibiotics, diagnose as protracted bacterial bronchitis (PBB) 2, 3

If cough persists after the initial 2-week course, prescribe an additional 2 weeks of appropriate antibiotics 2, 3

If cough persists after 4 weeks total of antibiotics, proceed to flexible bronchoscopy with quantitative cultures and consider chest CT 3

Red Flag "Specific Cough Pointers" Requiring Immediate Further Investigation:

• Coughing with feeding (aspiration risk) 3
• Digital clubbing (chronic suppurative lung disease) 3
• Chest deformity 3
• Growth failure 3
• Hemoptysis 2
• Persistent focal findings on examination 2

Management Algorithm for Dry/Non-Productive Cough

Do NOT empirically treat for asthma, GERD, or upper airway cough syndrome unless other clinical features consistent with these conditions are present 1, 2

For Suspected Asthma (requires supporting features):

• Look for associated wheeze, exercise intolerance, nocturnal symptoms, or family history of atopy 2
• In children >6 years with suspected asthma, consider testing for airway hyperresponsiveness (AHR) 1
• Administer albuterol and monitor clinical response with spirometry if available 2
• If empirical trial is used, define a limited duration to confirm or refute the diagnosis 1, 2

For Post-Infectious Cough:

• Consider this diagnosis if dry cough follows a recent respiratory infection 2
• These typically resolve spontaneously with time 4

For Suspected Pertussis:

• Undertake testing for recent Bordetella pertussis infection when clinically suspected (paroxysmal cough with post-tussive vomiting or inspiratory "whoop") 1, 3

Treatment of Acute Cough (<4 weeks)

For children >1 year old with acute cough, honey is the only recommended treatment 2

Do NOT use over-the-counter cough and cold medicines - they lack efficacy and have not been shown to reduce cough severity or duration 2, 5

Avoid codeine-containing medications due to risk of serious side effects including respiratory distress 2

• Dextromethorphan should not be used if cough lasts >7 days, occurs with too much phlegm, or in children with chronic cough from smoking, asthma, or emphysema 6

Critical Pitfalls to Avoid

Do not assume common adult etiologies (asthma, GERD, post-nasal drip) are common causes in children - age and clinical setting must guide your approach 1

Do not dismiss chronic wet cough as "just a cold" - persistent wet cough for >4 weeks requires active antibiotic management to prevent progression to bronchiectasis 3

Do not use the term "cough variant asthma" loosely - this diagnosis should only be made in older children after demonstrating variable airflow obstruction and bronchodilator response physiologically 7, 4

Do not delay diagnosis - early identification of conditions like foreign body aspiration or bronchiectasis prevents chronic respiratory morbidity 1

Environmental and Supportive Measures

Identify and advise cessation of environmental tobacco smoke exposure and other pollutants 2

Address parents' expectations and concerns directly 2, 4

When to Refer or Escalate

Consider referral for children who fail to respond to appropriate initial management or who present with hemoptysis, weight loss, or persistent focal findings 2

Refer children with recurrent episodes despite appropriate treatment or suspected anatomical abnormality requiring specialized evaluation 2