Diagnosis and Management of Chronic Cough in Pediatric Patients

Introduction

Cough constitutes a natural defense mechanism¹with a pervasive presence among both children and adults. Cough in children is identified as chronic by its duration of more than four weeks.¹Chronic cough can be better understood in Table 1.

Table1: Understanding Chronic Cough in Pediatric Patients²

Category

Details

Prevalence and Causes

	Mainly due to viral respiratory infections
	Other triggers: bacterial infections, allergies, asthma

Impact on Quality of Life

	Disrupts sleep, school performance, and play
	Lowers overall quality of life for children and families

Parental Stress and Anxiety

	Causes stress and anxiety in parents
	Concerns over disrupted behavior, eating, and sleep
	Fear of developing into serious conditions

Healthcare Burden

	Frequent cause of medical visits
	High costs from doctor visits, tests, and medications
	Significant impact on healthcare systems

Multidisciplinary
Management

Requires care from various medical specialties

Guideline Limitations

	Adult guidelines do not fit pediatric cases
	Need for more pediatric-specific guidelines

Once the fundamentals of chronic cough are understood, it becomes crucial to precisely identify the underlying cause, ensuring accurate diagnosis and appropriate treatment.²

Table 2: Methodical Diagnostic Framework for Chronic Cough in Children¹

The simplest and least-invasive diagnostic tool is history, which can make the diagnosis of habit cough (A) and provides historical pointers to consider diagnoses that require specific testing or therapeutic trials (B–F).

Observation and history: frequency of cough—repetitive cough absent once asleep indicates likelihood of habit cough syndrome

Cough present for < 3 months, especially if spasmodic and disturbs sleep, requires consideration of pertussis syndrome

Cough in infant with feeding warrants textured swallow study

Cough present since neonatal period, history of transient tachypnea of newborn, and chronic otitis media warrants consideration of primary ciliary dyskinesia

Cessation of cough after a short course of an oral corticosteroid is consistent with asthma; further evaluation can determine an appropriate treatment plan. Failure to stop cough with the oral corticosteroid warrants further evaluation

A 2-week therapeutic trial of amoxicillin-clavulanate can be considered as an alternative to bronchoscopy and lavage if the historical pointer suggests a “wet” cough in an infant or toddler in making a clinical diagnosis of protracted bacterial bronchitis

Radiology, chest X-ray or computerized axial tomography

	Lobar hyperinflation suggests retained foreign body—consider rigid bronchoscopy
	Suggestion of airway inflammation or bronchiectasis warrants sweat chloride testing for cystic fibrosis
	Situs inversus totalis suggests a likelihood of primary ciliary dyskinesia
	Normal chest X-ray warrants further evaluation

Flexible fiberoptic bronchoscopy with bronchoalveolar lavage can determine the following:

	Airway malacia, trachea or bronchi
	Protracted bacterial bronchitis

Table 3: Chronic Cough Treatment in Children¹
	Condition	Diagnosis Characteristics	Treatment
	Habit Cough	Repetitive cough absent during sleep	Suggestion therapy
	Asthma	Cough relieved by oral corticosteroids	Short course of oral corticosteroids; further evaluation for inhaled corticosteroid maintenance
	Pertussis	Severe contagious cough	Macrolide antibiotics (e.g., azithromycin)
	Cystic Fibrosis	Multi-system disease, chronic infections	Pancreatic enzyme replacement, mucolytics, antibiotics, airway clearance, CFTR potentiators and correctors
	Bronchiectasis	Chronic purulent cough	Airway clearance therapy, antibiotics, treat primary disease (e.g., cystic fibrosis, primary ciliary dyskinesia)
	Primary Ciliary Dyskinesia	Similar to cystic fibrosis but with less sticky mucus	Airway clearance therapy, antibiotics
	Protracted Bacterial Bronchitis	Persistent bacterial cough	2-week course of amoxicillin-clavulanate; possible longer or repeated treatments
	Tonsillar Cough	Cough due to anatomical abnormalities	Tonsillectomy or uvulectomy
	Tracheomalacia	Barking cough persistent during sleep	Aortopexy for severe cases

Based on current knowledge, there are unaddressed areas for improving chronic cough treatment in children due to limited guidelines and research.²Addressing these gaps identified by international experts (Table 4) is crucial for enhancing treatment outcomes.²

Table 4: Unmet Needs and Data Gaps in Pediatric Cough According to International Experts²

Greatest Unmet Needs in Pediatric Cough

Treatment
•	Effective, safe treatment for acute viral cough.
•	Faster resolution of cough symptoms.
•	Cough medication for children under 2 years.
•	Safe treatment for acute cough affecting sleep.
•	Mucolytics for dry cough.
•	Specific cough suppressants.
•	Testing and treatment for recurrent viral bronchitis.

Etiology, Progression & Others
•	Understanding cough causes.
•	Identifying cough phenotypes and treatments.
•	Preschool education on respiratory infection prevention and management.
•	Allergy research.
•	Clinical studies in pediatric populations.

Data Gaps in Pediatric Cough Research for Clinical Studies

Treatment
•	Controlled clinical trials on suggestion therapy for habit cough.
•	Effective treatments for viral cough.
•	Efficacy of over-the-counter cough medications.
•	Safety and effectiveness of symptomatic cough drugs.

Etiology, Progression & Others
•	Identifying cough phenotypes by age.
•	Assessing accuracy & changes in wet/dry cough reports.
•	Investigating primary infection sources in preschoolers.
•	Determining chronic cough prevalence and causes.

GGI-CO-A1-AQS-300033085-APPEMC-G24-0604
For the use of a Registered Medical Practitioner, Hospital or Laboratory only.
References:
1.	Weinberger M, Hurvitz M. Diagnosis and management of chronic cough: similarities and differences between children and adults. F1000Research. 2020; 9. Click hereto view the original article
2.	Vogelberg C, Cuevas Schacht F, Watling CP, Upstone L, Seifert G. Therapeutic principles and unmet needs in the treatment of cough in pediatric patients: review and expert survey. BMC pediatrics. 2023 Jan 21; 23(1):34. Click hereto view the original article

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Diagnosis and Management of Chronic Cough in Pediatric Patients

Diagnosis and Management of Chronic Cough in Pediatric Patients, Brozedex, Brozedex-ls, Chronic cough, Pediatrics, cough, Productive cough, General Practitioner

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