What is the appropriate workup and treatment for a pediatric patient with a 1-month history of intermittent cough?

Workup for Pediatric Patient with 1-Month Intermittent Cough

For a pediatric patient with a 1-month history of intermittent cough, first determine whether the cough is wet/productive or dry, then obtain a chest radiograph and spirometry (if age >3-6 years), and follow a systematic algorithm based on cough characteristics rather than empirical treatment. 1

Initial Assessment and Characterization

Determine Cough Type

• Classify the cough as either wet/productive or dry/non-productive, as this fundamentally determines the diagnostic pathway. 1, 2
• Evaluate for "specific cough pointers" including: coughing with feeding, digital clubbing, failure to thrive, hemoptysis, recurrent pneumonia, or abnormal chest examination findings. 1
• Assess environmental exposures, particularly tobacco smoke and other pollutants, and advise cessation. 1

First-Line Investigations

• Obtain a chest radiograph as the essential first-line investigation for all children with chronic cough (>4 weeks duration). 1, 2
• Perform spirometry if the child is >3-6 years old and trained pediatric personnel are available. 1, 2
• Do not routinely perform additional tests (skin prick testing, Mantoux, bronchoscopy, chest CT) unless specifically indicated by clinical findings. 2

Algorithm Based on Cough Characteristics

If Wet/Productive Cough WITHOUT Specific Pointers

• Diagnose protracted bacterial bronchitis (PBB) and treat with a 2-week course of antibiotics targeting common respiratory bacteria (Streptococcus pneumoniae, Haemophilus influenzae, Moraxella catarrhalis). 1, 2
• Appropriate antibiotic choices include amoxicillin-clavulanate or azithromycin (10 mg/kg once daily for 3 days or 10 mg/kg Day 1, then 5 mg/kg Days 2-5). 3
• If wet cough persists after 2 weeks of antibiotics, prescribe an additional 2-week course of appropriate antibiotics. 1, 2
• If wet cough persists after 4 weeks total of antibiotics, perform further investigations including flexible bronchoscopy with quantitative cultures and/or chest CT. 1, 2

If Wet/Productive Cough WITH Specific Pointers

• Immediately pursue further investigations including flexible bronchoscopy, chest CT, assessment for aspiration (barium swallow, video fluoroscopy), and evaluation of immunologic competency to assess for underlying disease such as bronchiectasis, aspiration, or immunodeficiency. 1

If Dry/Non-Productive Cough

• Evaluate for asthma if there are associated symptoms of wheeze, exercise intolerance, nocturnal symptoms, or reversible airway obstruction on spirometry. 1, 2
• Consider post-infectious cough if following a recent respiratory infection; 90% of post-viral coughs resolve by 3 weeks. 4
• Assess for upper airway cough syndrome (post-nasal drip) from chronic rhinosinusitis or allergic rhinitis. 1, 2

Do NOT empirically treat for asthma unless other features consistent with asthma are present (recurrent wheeze, dyspnea responsive to bronchodilators, documented reversible airway obstruction). 1, 2

Asthma Evaluation (If Suspected)

• Airway hyperresponsiveness testing in children is not as straightforward as in adults and may occur temporarily post-infections or with allergic rhinitis. 1
• The presence of airway hyperresponsiveness in a child with isolated cough does not predict response to asthma medications. 1
• If asthma is strongly suspected based on clinical pattern, a trial of bronchodilator (albuterol) with clinical and spirometric response assessment is appropriate. 2
• For children with chronic dry cough and asthma risk factors, a short defined trial of inhaled corticosteroids may be considered, but this should not exceed 2-4 weeks without reassessment. 1, 2

GERD Considerations

Do NOT treat for gastroesophageal reflux disease (GERD) when there are no gastrointestinal clinical features of GERD. 1

• GERD is NOT commonly identified as the cause of pediatric chronic cough, unlike in adults. 1
• Only consider GERD if specific GI symptoms are present: recurrent regurgitation, dystonic neck posturing in infants, or heartburn/epigastric pain in older children. 1
• Acid suppressive therapy should not be used solely for chronic cough, even when GERD symptoms are present. 1
• If GERD is suspected based on GI symptoms, treat according to evidence-based GERD-specific guidelines for 4-8 weeks and reevaluate response. 1

Important Clinical Pitfalls to Avoid

• Avoid empirical treatment approaches not based on specific findings or suspected diagnoses. 1, 2
• Do not use over-the-counter cough and cold medications, as they have not been shown to be effective and carry potential harm, especially in children under 2 years. 4
• Do not use codeine-containing medications due to potential serious side effects including respiratory distress. 2
• Proton pump inhibitors and H2 receptor antagonists should not be used for longer than 4-8 weeks without further evaluation. 1
• Any empirical trial should be of defined limited duration (2-4 weeks) to confirm or refute the hypothesized diagnosis. 2

When to Refer or Escalate

• Consider early consultation with a pediatric pulmonologist if wet cough persists after 4 weeks of appropriate antibiotics. 1
• Refer children who fail to respond to appropriate initial management or who present with concerning symptoms such as hemoptysis, weight loss, digital clubbing, or persistent focal findings. 2
• Consider referral for recurrent episodes despite appropriate treatment or suspected anatomical abnormality requiring specialized evaluation. 2

Reassessment Timeline

• For wet cough treated with antibiotics: reassess at 2 weeks, then every 2 weeks until cough resolves. 1
• For dry cough with asthma trial: reassess in 2-4 weeks. 1
• For GERD treatment (if indicated): reevaluate after 4-8 weeks. 1