What is the recommended evaluation and treatment for an 8-year-old female with a persistent cough lasting two weeks?

Evaluation and Management of Two-Week Cough in an 8-Year-Old Female

For an 8-year-old with a two-week cough, this falls into the "subacute" category (between acute and chronic), and the most likely diagnosis is postinfectious cough following a viral upper respiratory infection—watchful waiting with supportive care is appropriate at this time point, with reassessment if cough persists beyond 4 weeks. 1

Initial Classification and Approach

This two-week duration places the cough in a transitional zone:

• Not yet chronic: Chronic cough in children is defined as lasting ≥4 weeks 1
• Beyond simple acute: Most viral coughs resolve within 7-10 days, with 90% resolving by day 21 2
• Likely postinfectious: Subacute cough frequently follows an acute upper respiratory infection and represents persistent postnasal drip, upper airway irritation, mucus hypersecretion, or transient bronchial hyperresponsiveness 1

Immediate Evaluation Steps

History Points to Elicit

• Preceding viral illness: Was there a recent cold or upper respiratory infection? 1
• Cough characteristics: Is it dry/hacking or wet/productive? 2, 3
• Paroxysmal features: Any episodes of severe coughing fits followed by vomiting or inspiratory "whoop" sound? (suggests pertussis) 1, 4
• Environmental exposures: Tobacco smoke or other pollutants in the home? 1, 2
• Vaccination status: Is pertussis vaccination up to date? 4
• Associated symptoms: Fever, respiratory distress, difficulty feeding, or weight loss? 1, 2

Physical Examination Focus

• Respiratory rate and work of breathing: Look for tachypnea, retractions, or nasal flaring 2
• Auscultation: Listen for wheezing (suggests asthma) or crackles (suggests infection) 5, 3
• Oxygen saturation: Should be ≥92% 2
• General appearance: Signs of dehydration or distress 2

Diagnostic Testing at This Stage

• Chest radiograph is NOT routinely indicated at 2 weeks unless there are concerning features such as fever, respiratory distress, or abnormal lung sounds 1
• Spirometry is generally not needed at this early stage unless asthma is strongly suspected 3, 6

Management Strategy at Two Weeks

Supportive Care (Primary Approach)

• Maintain adequate hydration through continued fluid intake to help thin secretions 2
• Use saline nasal drops to relieve nasal congestion contributing to post-nasal drip 2
• Elevate head of bed during sleep for comfort 2
• Minimize environmental irritants, especially tobacco smoke exposure 1, 2

What NOT to Do

• Do NOT prescribe over-the-counter cough and cold medications in children under 6 years due to lack of efficacy and risk of adverse events 2
• Do NOT prescribe codeine-containing medications due to risk of serious respiratory side effects 2
• Do NOT prescribe antibiotics at this stage—a simple cough without fever, abnormal lung sounds, or productive sputum does not warrant antibiotics 2
• Do NOT prescribe asthma medications empirically unless there are other features of asthma such as recurrent wheeze, dyspnea, or documented bronchial hyperresponsiveness 2, 5

When to Escalate or Reassess

Immediate Return Warranted If:

• Respiratory distress develops (increased work of breathing, retractions) 2
• Fever appears 2
• Oxygen saturation drops below 92% 2
• Cough becomes paroxysmal with post-tussive vomiting or inspiratory "whoop" (suggests pertussis) 1, 4, 2
• Inability to feed or signs of dehydration 2

Scheduled Follow-Up at 4 Weeks If:

The cough persists beyond 4 weeks, at which point it meets the definition of chronic cough and requires systematic evaluation 1:

For dry/nonproductive cough at 4 weeks:

• Consider "nonspecific cough"—continue watchful waiting as most resolve spontaneously 2
• If associated with wheeze or dyspnea, consider trial of asthma therapy (inhaled corticosteroids and bronchodilators) 1, 5

For wet/productive cough at 4 weeks:

• Initiate a 2-week course of antibiotics targeting common respiratory bacteria (protracted bacterial bronchitis) 1, 2, 3
• If wet cough persists after 2 weeks of antibiotics, add another 2 weeks 4
• If wet cough persists after 4 weeks total of antibiotics, proceed to further investigation including chest radiograph and consideration of bronchiectasis, aspiration, or cystic fibrosis 1, 4

Special Consideration: Pertussis

If the cough pattern includes paroxysms, post-tussive vomiting, or inspiratory "whoop," pertussis must be strongly considered 1, 4:

• Pertussis is highly contagious with 80% secondary attack rate in susceptible contacts 4
• Obtain nasopharyngeal aspirate or swab for culture/PCR 1
• Initiate macrolide antibiotics (azithromycin or erythromycin) if clinically suspected, even before confirmation 4
• Infants <12 months with incomplete vaccination have highest risk of life-threatening complications 4

Common Pitfalls to Avoid

• Over-diagnosing asthma in children with isolated cough without wheeze or dyspnea 2, 5
• Premature use of antibiotics for what is likely a self-limited viral or postinfectious cough 2
• Prescribing cough suppressants like dextromethorphan, which lack efficacy in children 2
• Failing to reassess if cough persists beyond 4 weeks—this requires systematic evaluation for chronic cough causes 1

Parent Education

• Explain that most post-viral coughs resolve within 3 weeks and this is likely a self-limited process 2
• Provide clear return precautions for respiratory distress, fever, or change in cough pattern 2
• Emphasize that no medication is beneficial at this stage—supportive care is the evidence-based approach 2
• Ensure follow-up if cough persists beyond 4 weeks for systematic evaluation 1