Management of Chronic Cough in Children

Catherine K. Hart, MD, Alisa Timashpolsky, MD, and Michael A. DeMarcantonio, MD

Chronic cough in the pediatric population is defined as lasting more than four weeks and is one of the most common pediatric complaints in an otolaryngology practice. Chronic cough can be categorized into specific, nonspecific, and characteristic types based on underlying causes and patterns.

Key causes of chronic cough in children include asthma, gastroesophageal reflux disease (GERD), chronic bronchitis, sinusitis, and foreign body aspiration, with etiologies that vary by age and clinical setting. The diagnostic approach uses a modified algorithm based on guidelines published by the American College of Chest Physicians in 2006, considering factors such as timeline, symptoms, and potential triggers, including infections, allergies, and reflux.^1-3

An Australian study of 272 children found that early algorithm-based intervention reduced clinical failures compared with delayed treatment, reinforcing the value of structured approaches to managing pediatric cough.⁴

The presenters discussed treatment strategies based on the underlying cause, with options ranging from antibiotics for bacterial bronchitis, behavioral therapy for psychogenic cough, and non-pharmacological GERD treatments. In contrast with adults, cough in children usually has an identifiable cause. As such, cough hypersensitivity syndrome is not typically considered, and invasive treatments like nerve blocks are not recommended.

Evaluating chronic cough in children involves assessing diet, immunization status, history of trauma or intubation, neurodevelopmental abnormalities, and potential aspiration during swallowing, as well as a thorough physical exam for signs such as allergic shiners, nasal congestion, or failure to thrive.

Diagnosing Chronic Cough

Different cough types (e.g., barking, honking, staccato) can indicate specific conditions such as pertussis or psychogenic cough, and emerging machine learning tools show promise in diagnosing cough etiologies with high accuracy. Diagnostic tools include chest X-rays, CT scans, pulmonary function tests, allergy testing, sputum cultures, and video swallow studies; a pulmonology consultation is recommended for chronic or complex cases.

Chronic wet coughs often indicate protracted bacterial bronchitis or adenoiditis, typically treated with antibiotics and nasal steroids, while persistent dry coughs may benefit from inhaled corticosteroids after ruling out other causes. Persistent or severe cases may require advanced interventions like bronchoscopy, endoscopy, or surgical evaluation for structural abnormalities (e.g., laryngeal clefts), particularly in children with recurrent pneumonia or aspiration.

When using a two-dimensional endoscope, the presenters emphasized the importance of movement and technique, highlighting the need to evaluate for clefts during laryngoscopy and the limitations of flexible exams in reliably ruling out laryngeal clefts. “Cough pointers” are clues from history and exam findings that guide further evaluation, categorizing them into pulmonary, systemic, and otolaryngology-related disorders, such as recurrent infections, wheezing patterns, and chronic respiratory symptoms.

Pulmonary findings such as recurrent pneumonia, monophonic/polyphonic wheeze, and wet cough are linked to conditions such as laryngeal cleft, H-type fistula, or atypical infections, whereas systemic signs like failure to thrive or digital clubbing may indicate cystic fibrosis or other underlying issues.

Otolaryngology findings, including chronic rhinitis, adenoid hypertrophy, and reflux, are explored as potential causes of persistent cough, and shared decision-making and targeted treatments such as adenoidectomy or reflux management are recommended.

Diagnostic Challenges and Management Strategies

The presenters emphasized the importance of thorough investigation in cases of persistent or severe symptoms, and that unresponsive treatment may indicate underlying issues requiring further evaluation, such as airway foreign bodies or chronic conditions. Specific coughs with identifiable causes should be treated accordingly, while non-specific coughs often require observation and targeted interventions based on symptoms (e.g., antibiotics for wet cough, inhaled steroids for chronic dry cough).

Over-the-counter cough medicines for children are often ineffective, and the presenters recommended against their use and instead focused on treating the underlying cause of the cough. Honey can be used as a symptomatic treatment for non-specific cough—it has been used in medicine for a thousand years and is likely antibacterial, antiviral, and anti-inflammatory. However, honey should be avoided in children younger than 1 year to prevent botulism.

Conclusion

Chronic cough in children can be challenging to manage. However, the use of a well-established, rigorously studied clinical algorithm enables a systematic approach to this complex condition, leading to more effective treatment. Future research should focus on updating the algorithm as new evidence emerges and further refining its clinical application.

Disclosure: AI tools were used to capture and distill details of this presentation. All content has been reviewed and edited by the presenters.

References

1. Kennedy AA, Anne S, Hart CK. Otolaryngologic Management of Chronic Cough in School-aged Children: A Review. JAMA Otolaryngol Head Neck Surg. 2020 Nov 1;146(11):1059-1064.
2. Chang AB. Glomb WB. Guidelines for evaluating chronic cough in pediatrics: ACCP evidence-based clinical practice guidelines. Chest. 129(1 Suppl):260S-283S, 2006 Jan
3. Chang AB et al., Cough algorithm for chronic cough in children... Pediatrics; 2013, 131 (5) e1576-1583
4. Chang AB, Robertson CF, Van Asperen P, et al. A cough algorithm for chronic cough in children: a multicenter, randomized controlled study. Pediatrics. 2013;131(5):e1576–e1583. doi:10.1542/peds.2012-3318