Managing Chronic Cough As A Symptom In Children And Management Algorithms
Publication Date: March 1, 2020
Recommendations
1. For children aged ≤14 years, we suggest defining chronic cough as the presence of daily cough of more than 4 weeks in duration. (U-CBS)
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2. 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.
(1B)(b) their age and the clinical settings (eg, country and region) are taken into consideration when evaluating and managing their chronic cough.
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3. For children aged ≤14 years with chronic cough, we recommend using pediatric-specific cough management protocols or algorithms. (1B)
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4. 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. (1A)
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5. 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. (1A)
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6. 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. (1B)
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7. 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. ()
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8. 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. (1B)
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9. For children aged ≤14 years with chronic cough, we suggest undertaking tests evaluating recent Bordetella pertussis infection when pertussis is clinically suspected. (U-CBS)
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.
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10. 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. (1A)
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11. 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. (U-CBS)
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12. 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. (U-CBS)
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13. 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. (U-CBS)
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14. 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. (U-CBS)
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15. 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. (1A)
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16. 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. (1C)
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17. 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). (1C)
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18. 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. (2B)
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19. 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). (1C)
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20. 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. (1B)
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21. 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. (1B)
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22. 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, and
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(b) acid suppressive therapy should not be used solely for their chronic cough.
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23. 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. (U-CBS)
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24. For children aged ≤14 years with chronic cough (>4 weeks duration) without an underlying lung disease, if gastroesophageal reflux disease (GERD) is suspected as the cause based on GI symptoms, we suggest following the GERD guidelines for investigating children suspected for GERD. (U-CBS)
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25. 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. (U-CBS)
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26. 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. (2C)
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27. 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 many tics. (1C)
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28. 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.
(U-CBS)(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.
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29. 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. (2C)
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30. 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. (2C)
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31. For patients with cough in high TB prevalence countries or settings, we suggest:
(a) that they be screened for TB regardless of cough duration and
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(b) the addition of active case finding to passive case finding because it may improve outcomes in patients with pulmonary TB.
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32. 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 automated real-time nucleic acid amplification technology for rapid and simultaneous detection of TB and rifampin resistance (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. (U-CBS)
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33. 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. (U-CBS)
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34. 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 chest radiograph (CXR) if resources allow. (U-CBS)
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35. For children aged ≤14 years with chronic cough and suspected of having obstructive sleep apnea (OSA), we suggest that they are managed in accordance to sleep guidelines. (U-CBS)
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36. 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. (U-CBS)
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Table 1: Pointers to Presence of Specific Cougha
| Abnormality | Examples of etiology |
|---|---|
| Symptoms or signs | |
| Auscultatory findings | Wheeze–see below Crepitations–any airway lesions (from secretions) or parenchyma disease such as interstitial disease |
| Cardiac abnormalities | Associated airway abnormalities, cardiac failure, arrhythmia |
| Chest pain | Arrhythmia, asthma |
| Choked | Foreign body inhalation |
| Dyspnea or tachypnea | Any pulmonary airway or parenchyma disease |
| Chest wall deformity | Any pulmonary airway or parenchyma disease |
a As the causes of chronic cough encompasses the entire spectrum of pediatric pulmonology and extrapulmonary diseases, this list outlines the more common symptoms and signs and is not exhaustive.
37. For children aged ≤14 years with non-specific cough, we suggest when risk factors for asthma are present, a short (2-4 weeks) trial of 400 μg/day of beclomethasone equivalent may be warranted, and these children should always be re-evaluated in 2 to 4 week. (U-CBS)
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38. For children with acute cough, we suggest that the use of over the counter cough and cold medicines should not be prescribed until they have been shown to make cough less severe or resolve sooner. (U-CBS)
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39. For children with acute cough, we suggest that honey may offer more relief for cough symptoms than no treatment, diphenhydramine, or placebo, but it is not better than dextromethorphan. (U-CBS)
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40. For children with acute cough, we suggest avoiding using codeine-containing medications because of the potential for serious side effects including respiratory distress. (U-CBS)
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Recommendation Grading
Disclaimer
Overview
Title
Managing Chronic Cough As A Symptom In Children And Management Algorithms
Authoring Organization
American College of Chest Physicians
Publication Month/Year
March 1, 2020
Document Type
Guideline
External Publication Status
Published
Country of Publication
US
Document Objectives
Cough is one of the most common presenting symptoms to general practitioners. The objective of this article is to collate the pediatric components of the CHEST chronic cough guidelines that have recently updated the 2006 guidelines to assist general and specialist medical practitioners in the evaluation and management of children who present with chronic cough.
Target Patient Population
Children with chronic cough
Inclusion Criteria
Female, Male, Child
Health Care Settings
Ambulatory, Childcare center, Emergency care, Outpatient, School
Intended Users
Nurse, nurse practitioner, physician, physician assistant
Scope
Assessment and screening, Diagnosis, Management, Treatment
Diseases/Conditions (MeSH)
D001249 - Asthma, D001988 - Bronchiolitis, D010372 - Pediatrics, D003371 - Cough, D014917 - Whooping Cough, D005764 - Gastroesophageal Reflux
Keywords
pediatric, cough, chronic cough
Source Citation
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. doi: 10.1016/j.chest.2020.01.042. Epub 2020 Mar 14. PMID: 32179109.
Supplemental Methodology Resources
Methodology
Number of Source Documents
232
Literature Search Start Date
January 1, 2004
Literature Search End Date
April 25, 2019