What is the next step in managing an 8-year-old patient with a chronic cough (cough) lasting 3 months, normal chest X-ray (CXR), and no improvement with inhalers?

Next Step: Evaluate for Protracted Bacterial Bronchitis with Antibiotic Trial

For this 8-year-old with 3 months of cough, normal CXR, and failed inhaler therapy, the next step is to carefully characterize whether the cough is wet/productive versus dry, as this fundamentally determines management. 1, 2

Critical First Determination: Cough Characteristics

The management algorithm hinges entirely on whether this is a wet or dry cough 1:

If Wet/Productive Cough:

Start a 2-week course of antibiotics targeting common respiratory bacteria (Streptococcus pneumoniae, Haemophilus influenzae, Moraxella catarrhalis) based on local antibiotic sensitivities. 1, 2 This treats protracted bacterial bronchitis (PBB), the most common cause of chronic wet cough in children.

• If the cough resolves within 2 weeks, diagnose PBB and complete the antibiotic course 1, 2
• If wet cough persists after 2 weeks of appropriate antibiotics, extend treatment for an additional 2 weeks 1, 2
• If wet cough persists after 4 weeks total of antibiotics, further investigations are warranted (flexible bronchoscopy, chest CT, evaluation for aspiration, immunologic assessment) to assess for underlying disease like bronchiectasis 1, 2

If Dry/Non-Productive Cough:

This represents "non-specific cough" and should be managed with watchful waiting and re-evaluation in 2-4 weeks, as most cases resolve spontaneously. 1

• Do NOT use empirical asthma treatment unless other features of asthma are present (recurrent wheeze, exercise intolerance, nocturnal symptoms) 1, 2
• The failed inhaler trial already suggests asthma is unlikely unless it was inadequate dosing or duration 1
• Consider testing for airway hyperresponsiveness if asthma is still suspected clinically 1
• If asthma risk factors are present, a defined 2-4 week trial of inhaled corticosteroids (400 mcg/day beclomethasone equivalent) may be warranted, with mandatory re-evaluation 1, 2

Additional Investigations to Consider

Spirometry (pre and post-bronchodilator) should be performed if not already done, as this child is age-appropriate (>6 years). 1 While normal spirometry doesn't rule out asthma, abnormal results with bronchodilator reversibility would provide objective evidence supporting asthma diagnosis 1.

Evaluate for pertussis if there is post-tussive vomiting, paroxysmal cough, or inspiratory whoop. 1 Testing for recent Bordetella pertussis infection should be undertaken when clinically suspected 1.

What NOT to Do

• Do not empirically treat for GERD unless GI symptoms are present (recurrent regurgitation, heartburn, epigastric pain) 1, 2
• Do not routinely perform additional tests (skin prick test, Mantoux, bronchoscopy, chest CT) unless specific clinical pointers emerge 1, 2
• Do not use adult chronic cough algorithms - pediatric approaches differ fundamentally 3
• Avoid prolonged empirical treatment without defined endpoints and re-evaluation 1

Critical Cough Pointers Requiring Further Investigation

Re-examine for any "specific cough pointers" that would mandate immediate further workup 1:

• Digital clubbing, hemoptysis, or failure to thrive 1, 2
• Coughing with feeding (suggests aspiration) 1
• Abnormal chest examination findings 1
• Recurrent pneumonia or focal chest findings 2

If any of these are present, this is "specific cough" requiring investigations for bronchiectasis, foreign body, aspiration, cardiac anomalies, or interstitial lung disease 1.

Environmental and Parental Factors

• Determine and address environmental tobacco smoke exposure and other pollutants 1, 2
• Assess parental expectations and specific concerns 1, 2
• These factors should be addressed regardless of the underlying etiology 1

Follow-Up Timeline

All children with chronic cough must be re-evaluated within 2-4 weeks to monitor for emergence of specific etiologic pointers or response to treatment. 2, 3 The high rate of spontaneous resolution in pediatric chronic cough makes the "period effect" (natural resolution over time) a critical consideration when interpreting treatment response 1.