What is the best course of action for a 9-year-old female patient with a persistent cough (lasting 3 weeks), worsening at night when in a supine position, without fever?

Management of 3-Week Nocturnal Cough in a 9-Year-Old Girl

This 9-year-old girl with a 3-week cough that worsens at night when lying down, without fever, most likely has post-infectious cough or upper airway cough syndrome (UACS), and should be treated with a first-generation antihistamine-decongestant combination for 1-2 weeks as initial empiric therapy. 1

Clinical Context and Timing

This cough falls into the "prolonged acute cough" category (3-8 weeks duration), which allows time for natural resolution before extensive investigation. 2 The nocturnal worsening with supine positioning is a critical clue pointing toward either UACS or gastroesophageal reflux disease (GERD), though GERD is less common in this age group. 1

The absence of fever makes acute bacterial infection, pneumonia, or pertussis less likely. 3

Initial Empiric Treatment Approach

First-Line: Upper Airway Cough Syndrome Treatment

Start with a first-generation antihistamine-decongestant combination for 1-2 weeks. 1 The nocturnal worsening when lying down strongly suggests postnasal drip or upper airway involvement. 1 Look for accompanying symptoms such as:

• Throat clearing 1
• Sensation of postnasal drip 1
• Nasal congestion or rhinorrhea 1

Critical Pitfall: Avoid Asthma Overdiagnosis

Do not diagnose or treat for asthma based on cough alone in children. 4 The 2020 CHEST guidelines explicitly warn that "most children with isolated cough do not have asthma" and that "cough variant asthma is probably a misnomer for most children in the community who have persistent cough." 4

Key distinguishing features:

• Asthma-related cough is typically dry (not mentioned in this case) 4
• Asthma usually presents with wheeze, not isolated cough 4
• Only about 25% of children with cough symptoms actually have asthma 4

Sequential Treatment Algorithm if Initial Therapy Fails

Step 1: UACS Treatment (Current Recommendation)

• First-generation antihistamine-decongestant for 1-2 weeks 1

Step 2: If No Response After 1-2 Weeks

Only then consider asthma evaluation, which would require:

• Spirometry with bronchodilator response or bronchoprovocation challenge 1
• Look for cough worsening with cold air exposure or exercise 1
• Trial of bronchodilator therapy (response within 1 week, complete resolution up to 8 weeks) 1

Step 3: If Both UACS and Asthma Treatments Fail

Initiate intensive GERD therapy (though less common in children):

• High-dose proton pump inhibitor 1
• Dietary modifications 1
• Lifestyle changes 1
• Important: GERD therapy requires patience—response may take 2 weeks to several months 1

Post-Infectious Cough Consideration

If the cough began with an acute respiratory infection 3 weeks ago, consider post-infectious cough. 1, 2 This is extremely common in children and typically:

• Follows a viral upper respiratory infection 2
• May transition from dry to wet cough 2
• Often resolves spontaneously within 3-8 weeks 2

Treatment options for post-infectious cough:

• Inhaled ipratropium bromide as first-line 1
• Inhaled corticosteroids if ipratropium fails 1
• Short course of oral prednisone for severe paroxysms (after ruling out other causes) 1

What NOT to Do

Avoid prescribing:

• Expectorants or mucokinetic agents (no consistent benefit) 3
• Dextromethorphan or codeine as initial therapy in children (reserved for severe cases only) 4, 5
• Empiric antibiotics without evidence of bacterial infection 2

Do not order imaging at this stage unless red flags are present. 3 Chest radiography is warranted only if cough persists beyond 3 weeks without response to treatment or if concerning features develop. 3

Red Flags Requiring Expanded Workup

Proceed to chest radiograph and further evaluation if:

• Cough persists beyond 8 weeks despite treatment 1
• Development of systemic symptoms (fever, night sweats, weight loss) 1
• Hemoptysis 1
• Failure to thrive 6
• Abnormal lung sounds on examination 6

Persistent Bacterial Bronchitis Consideration

If the cough becomes wet/productive and persists after the initial viral illness resolved, consider persistent bacterial bronchitis. 2 This responds to a completed course of appropriate antibiotics (typically 2 weeks of amoxicillin-clavulanate). 2

Psychogenic Cough (Rare but Possible)

While uncommon, psychogenic cough can occur in this age group and presents with: 7

• Nonproductive cough with unusual pattern (e.g., staccato rhythm) 7
• Absent during sleep (key distinguishing feature) 7
• No response to medical therapy 7

However, this diagnosis should only be considered after thorough evaluation and failed therapeutic trials of common causes. 7