Chronic Cough (Paediatric)

Information

Children with chronic cough present with cough daily for at least 4 consecutive weeks without intermittent periods of being cough-free. The cough may worsen when there is a new respiratory tract infection. A structured cough history which includes the age and mode of onset, cough characteristics and time course/trajectory help determine the etiological classification, need for referral and treatment plan.

The nature of the cough is important: wet; dry; or chronic dry cough with episodes of wet cough. Distinguishing between a wet and dry cough can be difficult for parents and may not be accurate. Young children <5 rarely expectorate sputum but tend to swallow it and may vomit with the sputum seen in the vomitus.

Wet cough indicates an underlying cause of mucus hypersecretion or impaired mucociliary clearance, whereas a dry cough indicates an underlying cause of airway irritation or inflammation or a non-airway cause [13].

Predominant causes of chronic cough in children can usually be managed in primary care including: protracted bacterial bronchitis (PBB), allergic cough, asthma, post-infectious cough due to prolonged cough reflex hypersensitivity.

Children with PBB typically appear well apart from continuous chronic wet cough and are typically but not exclusively pre-school age. Cough resolves following a 2-4 week course of appropriate oral antibiotic against penicillin resistant pathogens.

paeds Chronic Cough guidelines — NHS Lothian

The Lothian Paediatric Chronic Cough Guideline gives a step-wise approach to presentation

https://apps.nhslothian.scot/files/sites/2/Dry-Cough-Guidelines-Paeds.pdf

Who can refer:

All primary care clinicians

Who to refer:

Red flags:

Pointers in the history or examination suggesting a specific respiratory diagnosis
Recurrence of protracted bacterial bronchitis (PBB) within 1 year (this conveys a risk of bronchiectasis)
Wet cough persisting following the Lothian Paediatric Chronic Cough Guideline
Parental anxiety or need for reassurance

Who not to refer:

Where there are effective treatments available in primary care
When reassurance and support in primary care is sufficient
Recurrent viral cough episodes and otherwise well. Some children experience up to 8-10 upper respiratory tract infections per year and can cause almost continuous symptoms for many weeks, particularly in pre-school aged children.

How to refer:

Please send electronic referral via SCI-gateway to:

RHCYP> Respiratory Medicine > Ll Basic Sign Referral

For West Lothian patients:

St John’s Hospital > Paediatrics > LI Basic Sign Referral

Investigations to be included with referral:

See Lothian Paediatric Chronic-Cough-Guidelines.pdf

Examination of chest, ears, nose and throat

All presentations with red flags should be marked urgent and consider directing the patient to A&E.

Lothian Paediatric Chronic Cough Guideline (add PDF)

Major aetiological causes of chronic cough in children and examples.

Post-infectious: typically shows spontaneous resolution over time
Airway infections (protracted/recurrent/persistent): Protracted bacterial bronchitis (PBB), chronic suppurative lung disease, bronchiectasis, cystic fibrosis (CF), immune deficiency/primary ciliary dyskinesia (PCD), other chronic infections e.g., tuberculosis and atypical mycobacteria
Airway anomaly: Primary or secondary tracheobronchomalacia, congenital airway and pulmonary malformation
Airway inflammation: Asthma, eosinophilic bronchitis, environmental pollutants
Airway aspiration: Primary airway aspiration, secondary aspiration owing to gastroesophageal reflux, foreign body aspiration
Upper airway associations: Rhinitis, sinusitis
Tic and somatic syndrome
Extra-pulmonary: Drug-induced, cardiac, vagal nerve branches stimulation (e.g., Arnold’s ear reflex)
Other specific diseases associated with chronic cough: Interstitial lung disease or tumours