Chronic Cough in Kids Can Be Frustrating

July 30th 2018

A recent publication describes a structured approach to chronic cough in children.

Almost all kids develop an acute cough several times a year; the average child has 3 to 4 respiratory tract infections annually. Some researchers have found that up to 1/3 of children may have an acute cough at any given time. Some kids, however, develop chronic cough (daily coughing lasting longer than 4 to 8 weeks).

It can be difficult for clinicians to tease out specific causes of chronic cough. It is also frustrating for parents who often make multiple appointments with healthcare providers, and still have no answer as to why their child continues to cough. Cough can disturb the child’s and the family’s sleep, and interfere with school, work, and leisure activities.

TheArchives of Disease in Childhood, Education and Practice Editionhas published a manuscript that describes a structured approach to chronic cough in children. These authors indicate that chronic cough has 5 etiologies. These include chronic cough in normal child, chronic cough in a child with serious underlying illness, upper airway cough syndrome (previously called postnasal drip syndrome), asthma syndrome, or psychogenic cough.

The authors remind clinicians that cough can occur pursuant to bacterial or viral respiratory infection. Some children develop a post infectious illness, often caused bymycoplasma, pertussis, or chlamydia. Some children may develop tuberculosis although it is rare. Atopic conditions (asthma and allergic rhinitis) are also notorious causes of cough.

Clinicians should also be aware that chronic suppurative lung disease including cystic fibrosis, immune deficiencies, primary ciliary dyskinesia, bronchiectasis of any origin, and protracted bacterial bronchitis.

A strength of this review is that it describes various coughs (e.g. sudden onset, barking/brassy, paroxysmal, dry, honking…) and connects them with possible diagnoses. It also provides guidance on diagnostic testing. Although management of each of these is beyond the article’s scope, the authors address the common situation of children who have chronic cough, normal chest x-rays, and spirometry results, the absence of underlying disease, and parents who pressure healthcare providers for resolution of the cough.

The first step is to determine whether the cough is dry or wet. Children who have dry cough tend to improve spontaneously, and the authors indicate that clinician should discourage use of over-the-counter cough medications. They should also advise parents and patients to avoid aerosol irritants like tobacco smoke. If parents smoke, healthcare providers have an opportunity to counsel about smoking cessation. If the cough persists, inhaled corticosteroids are a possible option over an 8-week period at an appropriate dose.

In children who have wet cough, the diagnosis may be protracted bacterial bronchitis. They indicate this particular condition is underrecognized, and undertreated. A barrier to recognition and treatment is the reluctance to prescribe prolonged courses of antibiotics in children. In this case, antibiotics can eradicate the bacterial biofilm and should be used for 2 to 3 weeks.

Reference

Alviani C, Ruiz G, Gupta A. Fifteen-minute consultation: A structured approach to the management of chronic cough in a child.Arch Dis Child Educ Pract Ed.2018;103(2):65-70.

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