| This article encapsulates physician-focused recommendations and suggestions for managing chronic cough in pediatric patients, derived from robust systematic reviews. |
| Summary of Recommendations and Suggestions1,2 |
|
|
| For children aged ≤ 14 years, we suggest defining chronic cough as the presence of daily cough of more than 4 weeks in duration (Ungraded Consensus-Based Statement). |
|
|
| For children aged ≤ 14 years, we recommend that (a) common etiologies of chronic cough in adults are not presumed to be common causes in children and (b) their age and the clinical settings (eg, country and region) are taken into consideration when evaluating and managing their chronic cough (Grade 1B). |
|
|
| For children aged ≤ 14 years with chronic cough, we recommend using pediatric-specific cough management protocols or algorithms (Grade 1B). |
|
|
| For children aged ≤ 14 years with chronic cough, we recommend taking a systematic approach (such as using a validated guideline) to determine the cause of the cough (Grade 1A). |
|
|
| For children aged ≤ 14 years with chronic cough, we recommend basing the management or testing algorithm on cough characteristics and the associated clinical history such as using specific cough pointers like presence of productive/wet cough (Grade 1A). |
|
|
| For children aged ≤ 14 years with chronic cough, we recommend that a chest radiograph and, when age appropriate, spirometry (pre and post β2 agonist) be undertaken (Grade 1B). |
|
|
| For children aged > 6 years and ≤ 14 years with chronic cough and asthma clinically suspected, we suggest that a test for airway hyper-responsiveness be considered (Grade 2C). |
|
|
| For children aged ≤ 14 years with chronic cough, we recommend not routinely performing additional tests (eg, skin prick test, Mantoux, bronchoscopy, chest CT); these should be individualized and undertaken in accordance to the clinical setting and the child’s clinical symptoms and signs (Grade 1B). |
|
|
| For children aged ≤ 14 years with chronic cough, we suggest undertaking tests evaluating recent Bordetella pertussis infection when pertussis is clinically suspected (Ungraded Consensus-Based Statement). |
|
|
| Remarks: CHEST guidelines suggested that clinicians consider cough could be considered caused by pertussis if there is post-tussive vomiting, paroxysmal cough or inspiratory whoop. |
|
|
| For children aged ≤ 14 years with chronic cough, we recommend basing the management on the etiology of the cough. An empirical approach aimed at treating upper airway cough syndrome due to a rhinosinus condition, gastroesophageal reflux disease and/or asthma should not be used unless other features consistent with these conditions are present (Grade 1A). |
|
|
| For children aged ≤ 14 years with chronic cough, we suggest that if an empirical trial is used based on features consistent with a hypothesized diagnosis, the trial should be of a defined limited duration in order to confirm or refute the hypothesized diagnosis (Ungraded Consensus-Based Statement). |
|
|
| For children aged ≤ 14 years with chronic cough, we suggest that clinical studies aimed at evaluating cough etiologies use validated cough outcomes, use a-priori defined response and diagnosis, and take into account the period effect, and undertake a period of follow-up (Ungraded Consensus-Based Statement). |
|
|
| For children aged ≤ 14 years with chronic cough, we suggest that exacerbating factors such as environmental tobacco smoke exposure should be determined and intervention options for cessation advised or initiated (Ungraded Consensus-Based Statement). |
|
|
| For children aged ≤ 14 years with chronic cough, we suggest that parental (and when appropriate the child’s) expectations be determined, and their specific concerns sought and addressed (Ungraded Consensus-Based Statement). |
|
|
| For children aged ≤ 14 years with chronic (> 4 weeks duration) wet or productive cough unrelated to an underlying disease and without any other specific cough pointers (eg, coughing with feeding, digital clubbing), we recommend 2 weeks of antibiotics targeted to common respiratory bacteria (Streptococcus pneumoniae, Haemophilus influenzae, Moraxella catarrhalis) targeted to local antibiotic sensitivities (Grade 1A). |
|
|
| For children aged ≤ 14 years with chronic (> 4 weeks duration) wet or productive cough unrelated to an underlying disease and without any other specific cough pointers (eg, coughing with feeding, digital clubbing) and whose cough resolves within 2 weeks of treatment with antibiotics targeted to local antibiotic sensitivities, we recommend that the diagnosis of PBB be made (Grade 1C). |
|
|
| For children aged ≤ 14 years with chronic (> 4 weeks duration) wet or productive cough unrelated to an underlying disease and without any other specific cough pointers (eg, coughing with feeding, digital clubbing), when the wet cough persists after 2 weeks of appropriate antibiotics, we recommend treatment with an additional 2 weeks of the appropriate antibiotic(s) (Grade 1C). |
|
|
| For children aged ≤ 14 years with chronic (> 4 weeks duration) wet or productive cough unrelated to an underlying disease and without any other specific cough pointers (eg, coughing with feeding, digital clubbing), when the wet cough persists after 4 weeks of appropriate antibiotics, we suggest that further investigations (eg, flexible bronchoscopy with quantitative cultures and sensitivities with or without chest CT) be undertaken (Grade 2B). |
|
|
| For children aged ≤ 14 years with PBB with lower airway (BAL or sputum) confirmation of clinically important density of respiratory bacteria (≥ 104 cfu/mL), we recommend that the term ‘microbiologically-based-PBB’ (or PBB-micro) be used to differentiate it from clinically-based-PBB (PBB without lower airway bacteria confirmation) (Grade 1C). |
|
|
| For children aged ≤ 14 years with chronic wet or productive cough unrelated to an underlying disease and with specific cough pointers (eg, coughing with feeding, digital clubbing), we recommend that further investigations (eg, flexible bronchoscopy and/or chest CT, assessment for aspiration and/or evaluation of immunologic competency) be undertaken to assess for an underlying disease (Grade 1B). |
|
|
| For children aged ≤ 14 years with chronic cough (> 4 weeks duration) without an underlying lung disease, we recommend that treatment(s) for GERD should not be used when there are no GI clinical features of gastroesophageal reflux such as recurrent regurgitation, dystonic neck posturing in infants or heartburn/ epigastric pain in older children (Grade 1B). |
|
|
| For children aged ≤ 14 years with chronic cough (> 4 weeks duration) without an underlying lung disease, who have symptoms and signs or tests consistent with gastroesophageal pathological reflux, we recommend that (a) they be treated for GERD in accordance to evidence-based GERD-specific guidelines (Grade 1B) and (b) acid suppressive therapy should not be used solely for their chronic cough (Grade 1C). |
|
|
| For children aged ≤ 14 years with chronic cough (> 4 weeks duration) without an underlying lung disease, with GI gastroesophageal reflux (GER) symptoms, we suggest that they be treated for GERD in accordance to evidence-based GERD-specific guidelines for 4 to 8 weeks and their response reevaluated (Ungraded Consensus-Based Statement). |
|
|
| For children aged ≤ 14 years with chronic cough (> 4 weeks duration) without an underlying lung disease, if GERD is suspected as the cause based on GI symptoms, we suggest following the GERD guidelines for investigating children suspected for GERD (Ungraded Consensus-Based Statement). |
|
|
| For children with chronic cough (> 4 weeks) after acute viral bronchiolitis, we suggest that the cough be managed according to the CHEST pediatric chronic cough guidelines, asthma medications not be used for the cough unless other evidence of asthma is present, and inhaled osmotic agents not be used (Ungraded Consensus-Based Statement). |
|
|
| For children with chronic cough, we suggest that the presence or absence of night time cough or cough with a barking or honking character should not be used to diagnose or exclude psychogenic or habit cough (Grade 2C). |
|
|
| For children with chronic cough that has remained medically unexplained after a comprehensive evaluation based upon the most current evidence-based management guideline, we recommend that the diagnosis of tic cough be made when the patient manifests the core clinical features of tics that include suppressibility, distractibility, suggestibility, variability, and the presence of a premonitory sensation whether or not the cough is single or one of manytics (Grade 1C). |
|
|
| For children with chronic cough, we suggest (a) against using the diagnostic terms habit cough and psychogenic cough and (b) substituting the diagnostic term tic cough for habit cough to be consistent with the DSM-5 classification of diseases because the definition and features of a tic capture the habitual nature of cough and (c) substituting the diagnostic term somatic cough disorder for psychogenic cough to be consistent with the DSM-5 classification of diseases (Ungraded Consensus-Based Statement). |
|
|
| For children with chronic cough, we suggest that the diagnosis of somatic cough disorder can only be made after an extensive evaluation has been performed that includes ruling out tic disorders and uncommon causes and the patient meets the DSM-5 criteria for a somatic symptom disorder (Grade 2C). |
|
|
| For children with chronic cough, diagnosed with somatic cough disorder (previously referred to as psychogenic cough), we suggest non-pharmacological trials of hypnosis or suggestion therapy or combinations of reassurance, counselling, or referral to a psychologist and/or psychiatrist (Grade 2C). |
|
|
| For patients with cough in high TB prevalence countries or settings, we suggest (a) that they be screened for TB regardless of cough duration (Grade 2C) and (b) the addition of active case finding to passive case finding because it may improve outcomes in patients with pulmonary TB (Ungraded Consensus-Based Statement). |
|
|
| For patients with cough and at risk of pulmonary TB but at low risk of drug-resistant TB living in high TB prevalence countries, we suggest that XpertMTB/RIF testing, when available, replace sputum microscopy for initial diagnostic testing, but CXRs should also be done on pulmonary TB suspects when feasible and where resources allow (Ungraded Consensus-Based Statement). |
|
|
| For patients with cough suspected to have pulmonary TB and at high risk of drug-resistant TB, we suggest that XpertMTB/RIF assay, where available, replace sputum microscopy but sputum mycobacterial cultures, drug susceptibility testing and CXRs should be performed when feasible and where resources allow (Ungraded Consensus-Based Statement). |
|
|
| For patients with cough with or without fever, night sweats, hemoptysis, and/or weight loss, and who are at risk of pulmonary TB in high TB prevalence countries, we suggest that they should have a CXR if resources allow (Ungraded Consensus-Based Statement). |
|
|
| For children aged ≤ 14 years with chronic cough and suspected of having OSA, we suggest that they are managed in accordance to sleep guidelines (Ungraded Consensus-Based Statement). |
|
|
| For children aged ≤ 14 years with non-specific cough, we suggest that if cough does not resolve within 2 to 4 weeks, the child should be re-evaluated for emergence of specific etiological pointers (Ungraded Consensus-based Statement). |
|
|
