Chronic cough in children 15 years and younger usually is defined as a daily cough
lasting four or more weeks (Chang AB et al., 2020). Cough can be classified based on the
duration of cough, quality (dry or wet, brassy or staccato), or based on etiology (specific vs
nonspecific). Specific cough refers to a chronic cough that is ultimately attributable in majority
of the cases to an underlying identifiable respiratory disease of known etiology, while
nonspecific cough, dry cough refers to chronic cough in the absence of an identifiable respiratory
disease (Chang AB et al., 2020). The etiology of nonspecific cough includes post-respiratory
viral infections, the inhalation of a foreign body, airway lesions, environmental toxins/irritants,
non-asthmatic eosinophilic bronchitis, medication side effect, and otogenic causes (Chang AB et
al., 2012).
In most cases, an initial work-up consisting of a focused history, physical examination,
chest radiography, and spirometry will identify features that serve as clues to the underlying
disease. The choice of investigations will be determined by the patient demographic and access
to resources, among other things. Adverse events to investigations must be considered as, in
children, some investigations such as CT scans have a higher risk from radiation and general
anesthesia (if required) when compared with adults (Chang AB et al., 2015).
A large multicenter cohort study by Chang AB et al. (2015) involving children newly
referred for chronic cough (median duration, 3-4 months) have determined that children with
chronic dry cough without any specific cough pointers can be safely managed using the watchful
waiting approach as most cases resolved spontaneously. While cough associated with “specific
cough pointers”, including chest pain, dyspnea, digital clubbing, feeding problems, failure to
thrive, and abnormal pulmonary auscultation, should warrant further investigations and early
management/intervention of the underlying etiology would yield better clinical outcome (Kasi
Ajay and Kamerman Kretzmer, 2019).
Chronic cough is associated with poor quality of life and may signify a serious
underlying disease. In general, the management of specific cough should be based on etiology.
When the underlying condition or exacerbating factor is managed, cough subsequently resolves.
However, in cases of nonspecific cough, respiratory viral infections are likely the most common
cause of "nonspecific" chronic cough without any specific cough "pointers". The underlying
physiology is thought to be due to increased sensitivity of the cough reflex that gradually
resolves over time (Chang AB et al., 2012). Not only there is no evidence for using medications
for the symptomatic relief of cough but the use of prescription and non-prescription medications
may result in adverse events including Cushing's disease and accidental poisoning (Gunn VL et
al., 2001). It is advisable that these patient and family be managed with reassurance and followup in two to four weeks (Chang AB et al., 2015).
Cough often impacts the quality of life of both children and parents, and the exploration
of parental expectations and fears is often valuable in the management of cough in children. If
medications are used, it is imperative that the children are followed up and therapy with the
medications stopped if there is no effect on the cough within an expected time frame (Chang AB
et al., 2015). Irrespective of diagnosis, identifying and mitigating exacerbation factors, such as
exposure to environmental tobacco smoke and other triggers should be included in the
patient/caregiver education and plan of care. Chronic cough in children (aged < 15 years) should
be managed according to child-specific guidelines, which differ from those for adults as the
etiology and management for children are not common in most cases (Chang AB et al., 2015).
Patient should be advised to regularly follow up, and return for re-evaluation if the chronic cough
does not resolve over the next month or so and if new symptoms emerge.
References
Chang AB, Oppenheimer JJ, Irwin RS; CHEST Expert Cough Panel. Managing Chronic Cough
as a Symptom in Children and Management Algorithms: CHEST Guideline and Expert Panel
Report. Chest. 2020 Jul;158(1):303-329.
Kasi AS, Kamerman-Kretzmer, RJ. Cough. Pediatrics in Review 2019 Apr; 40(4):157-167.
Chang AB, Van Asperen PP, Glasgow N, Robertson CF, Mellis CM, Masters IB, Landau LI,
Teoh L, Tjhung I, Petsky HL, Morris PS. Children with chronic cough: when is watchful waiting
appropriate? development of likelihood ratios for assessing children with chronic cough. Chest.
2015 Mar;147(3):745-753.
Chang AB, Robertson CF, Van Asperen PP, Glasgow NJ, Mellis CM, Masters IB, Teoh L,
Tjhung I, Morris PS, Petsky HL, Willis C, Landau LI. A multicenter study on chronic cough in
children: burden and etiologies based on a standardized management pathway. Chest. 2012
Oct;142(4):943-950.
Gunn VL, Taha SH, Liebelt EL, Serwint JR. Toxicity of over-the-counter cough and cold
medications. Pediatrics. 2001 Sep;108(3):E52.