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.
Chronic Dry-Cough-Guidelines-Paeds.pdf
Who can refer:
All primary care clinicians
Who to refer:
- Cough with 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
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
for further details see Chronic-Cough-Pointers.pdf
Chronic Cough Pointers guide PDF
The Following references were used in creating this page:
The child with an incessant dry cough; Galway and Shields 2018; doi: 10.1016/j.prrv.2018.08.002
History taking as a diagnostic tool in children with chronic cough; Kantar et al 2022; doi: 10.3389/fped.2022.850912
ERS statement on protracted bacterial bronchitis in children; Kantar et al 2017; doi: 10.1183/13993003.02139-2016
ERS guidelines on the diagnosis and treatment of chronic cough in adults and children; Moric et al 2020; doi: 10.1183/13993003.01136-2019
2022 GINA Main Report- Global Initiative for Asthma – GINA https://ginasthma.org/gina-reports
Recommendations for the assessment and management of cough in children – Shields et al 2008 doi: 10.1136/thx.2007.077370
NICE asthma guidelines; https://cks.nice.org.uk/topics/asthma/
