Management of Chronic Cough in Children

- Recommendations

Table 3. Recommendations
A. Evaluating children aged ≤ 14 years with chronic cough:
N	Health questions	Source Guideline	Recommendations	Quality of evidence	Strength of Recommendation
A1	What is the value of estimating the duration of cough?	ACCP 2020	For patients seeking medical care complaining of cough, clinician suggest that estimating the duration of cough is the first step in narrowing the list of potential diagnoses.	Low	Weak (Conditional)
A2	Should history include specific cough pointers?	ACCP 2020	History should include cough characteristics and the associated clinical history such as using specific cough pointers like presence of productive/wet cough.	High	Strong
A3	Should history include red flags?		History should include symptoms of red flags or other potential life-threatening symptoms and if present, they should be immediately addressed and evaluated.		Good Practice statement Glashan and Mahmoud, 2019 (40)
A4	What is the value of detailed history to determine environmental exposure to respiratory irritants?	ERS 2019	Exposure to airborne irritants (e.g. tobacco exposure, combustions, traffic related exposure etc.), allergens or infection may be a reason for dry chronic cough.	Very low	Weak (conditional)
A5	Is history suggestive of OSA (mouth breathing, snoring, restless sleep, morning somnolence, daytime sleepiness and poor academic achievement) important for the diagnosis?	Korean 2016	In unexplained or unresponsive chronic cough, obstructive sleep apnea should be included in the differential diagnosis.	Very low	Weak (conditional)
A6	Is history of drug intake important to evaluate cough?	ERS 2019	Detailed history of drug intake is needed including ACEI and other drugs such as bisphosphonates or calcium channel antagonists and prostanoid eye drops.	Very low	Weak (conditional)
A7	What is the importance of clinical evaluation of upper airway cough syndrome due to a rhinosinus condition, gastroesophageal reflux disease and/or asthma before starting any empiric therapy for these conditions?	ACCP 2020	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.	High	Strong
A8	8a- How to suspect asthma from history?	ACCP 2020	Diagnosis of asthma is suggested by presence of risk factors and/or response to a short (2-4 weeks) therapeutic trial of 400 ug/day of beclomethasone equivalent may be warranted, and these children should be evaluated in 2-4 weeks.	Very low	Weak (conditional)
	8 b- How to suspect cough variant asthma by history?	ERS 2019 Korean 2016	Cough variant asthma (CVA) was originally described as asthma with cough as the sole symptom and where treatment with bronchodilators improved coughing	Very low Very low	Weak (conditional) Weak (conditional)
A9	How to suspect TB in a child with chronic cough	ACCP 2020	Patients with cough with or without fever, night sweats, hemoptysis, weight loss and/or contact with TB case and -who are at risk of pulmonary TB in community high in TB prevalence.	Very low	Weak (conditional)

Table 4. Recommendations
B. Investigations
N	Health questions	Source Guideline	Recommendations	Quality of evidence	Strength of Recommendation
B10	10a-Should the clinician recommend chest radiography?	ACCP 2006-2020	The clinician should recommend chest radiography.	Intermediate	Strong
B10	10b- Should chest CT scan be routinely performed for children with normal physical examination and plain chest X-ray?	ERS 2019	The clinician should not routinely perform a chest CT scan in patients who have normal physical examination and chest X-ray.	Very low	Weak (Conditional)
B11	11a- When age is appropriate, should the clinician recommend spirometry (pre and post β2 agonist)?	ACCP 2006-2020	The clinician should recommend spirometry (pre and post β2 agonist) when age is appropriate.	Intermediate	Strong
B11	11b- For children aged > 6 years and asthma is clinically suspected, should the clinician suggest a test for airway hyper-responsiveness?	ACCP 2006-2020	The clinician should suggest a test for airway hyper-responsiveness (mannitol or methacholine inhalation).	Low	Weak (conditional)
	11c- Should FeNO (if available)/blood eosinophil count be used in aiding the diagnosis or predicting the treatment response when asthma is clinically suspected?	ERS 2019	This recommendation places relatively higher value on predictability for the treatment response and the impact on the treatment decision.	Very low	Weak (conditional)
B12	Should the clinician perform additional tests (e.g. skin prick test, Mantoux, bronchoscopy, chest CT)?	ACCP 2006-2020	Clinicians should not routinely perform additional tests. These should be individualized and undertaken according to the child’s clinical symptoms and signs.	Intermediate	Strong
B13	Should the clinician suggest undertaking tests for evaluating recent Bordetella pertussis infection when pertussis is clinically suspected?	ACCP 2020	The clinician should suggest undertaking tests for evaluating recent Bordetella pertussis infection when pertussis is clinically suspected (if there is post-tussive vomiting, paroxysmal cough or inspiratory whoop).	Very low	Weak (conditional)
B14	14a- Should the clinician suggest further investigations when wet cough (unrelated to an underlying disease and with no specific cough pointers) persists after 4 weeks of appropriate antibiotics?	ACCP 2006-2020	The clinician should suggest further investigations (e.g. flexible bronchoscopy with quantitative culture and sensitivity with or without chest CT assessment for aspiration) to be undertaken.	Intermediate	Strong
B14	14b- Should the clinician recommend evaluation of immunologic competence for children with wet cough unrelated to an underlying disease and with specific cough pointers?	ACCP 2006	The clinician should recommend evaluation of the immunologic competence in presence of criteria suspicious of immunodeficiency (appendix) to assess for an underlying disease.	Intermediate	Strong
B15	For children with chronic productive purulent cough, do you recommend investigations to document the presence or absence of bronchiectasis?	ACCP 2012	In patients with suspected bronchiectasis without a characteristic chest radiograph finding, a high-resolution CT (HRCT) scan of the chest should be ordered because it is the diagnostic procedure of choice to confirm the diagnosis.	Low	Strong
B16	16a- In patients evaluated for GERD, what is the most sensitive and specific tests for the diagnosis?	ACCP 2006-2020	A 24-h esophageal pH monitoring test is the most sensitive and specific test.	Low	Strong
B16	16b- Is barium esophagography beneficial for diagnosing GERD as the cause of cough?	ACCP 2012	Barium esophagography may be beneficial. It can be considered if it is the only available test to reveal that GERD is of potential pathologic significance.	Low	Strong
	16c-In patients with suspected GERD, are the esophagoscopy findings helpful to rule out GERD as the cause of cough?	ACCP 2012	A normal esophagoscopy finding does not rule out GERD as the cause of cough.	Low	Strong
B17	17a- Should the clinician suggest screening for TB to patients in high TB prevalence countries or settings?	ACCP 2020	The clinician should suggest screening for TB regardless of cough duration.	low	Strong
B17	17b- Should the clinician suggest Xpert MTB/RIF test, when available, to replace sputum microscopy as an initial diagnostic test for patients with high risk of pulmonary TB but at low risk of drug-resistance?	ACCP 2020	The clinician should suggest Xpert MTB/RIF test, when available, to replace sputum microscopy as an initial diagnostic tests.	Very low	Weak (conditional)
B18	For children with upper airway symptoms, should the clinician advise for routine laryngoscopy, rhinoscopy or CT sinuses?		In patients who report upper airway symptoms laryngoscopy, rhinoscopy or CT sinuses may be performed but not routinely.		Good practice statement O'Hara & Jones 2006 (25)
B19	For children with non-specific cough, if cough does not resolve within 2 to 4 weeks, should the child be re-evaluated for emergence of specific etiological pointers?	ACCP 2020	For children 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.	Very low	Weak (conditional)

Table 5. Recommendations
C. Treatment
N	Health questions	Source Guideline	Recommendations	Quality of evidence	Strength of Recommendation
C20	21a-What is the recommended treatment for children aged > 6 years and < 14 years with clinically suspected asthma	ACCP 2020	When risk factors for asthma are present, a short (2-4 weeks) trial of 400 microgram/day of beclomethasone equivalent, and re-evaluated	Intermediate	Strong
C20	21b- Should asthma medications be used after acute viral bronchiolitis if cough persist for more than 4 weeks?	ACCP 2020	Asthma medications should not be used for cough unless other evidence of asthma is present.	Very low	Weak (conditional)
C21	Should an empirical approach aiming at treating upper airway cough syndrome due to a rhinosinus condition, gastroesophageal reflux disease or asthma be used?	ACCP 2020	1- An empirical approach should not be used unless other features consistent with these conditions are present. 2-- If an empirical trial is used, the trial should be of a defined limited duration in order to confirm or refute the hypothesized diagnosis.	High Very low	Strong Weak (conditional)
C22	What are the recommendations for wet or productive cough unrelated to an underlying disease and without any other specific cough pointers?	ACCP 2020	1-Two weeks of antibiotics targeting the common respiratory bacteria (Streptococcus pneumoniae, Haemophilus influenzae, Moraxella catarrhalis) and depending on the local antibiotic sensitivities. 2- The diagnosis of PBB be made 3- When the wet cough persists after2 weeks of appropriate antibiotics, consider treatment with an additional 2 weeks of the appropriate antibiotic(s). 4- When the wet cough persists after 4 weeks of appropriate antibiotics, further investigations as flexible bronchoscopy with quantitative cultures and sensitivities with or without chest CT) can be undertaken	High Low Intermediate Intermediate	Strong Strong Strong Strong
C23	What is the treatment in children without an underlying lung disease who have symptoms and signs or tests consistent with gastroesophageal pathological reflux?	ACCP 2020	a) They can be treated for GERD according to evidence-based GERD-specific guidelines. (b) Acid suppressive therapy should not be used solely for their chronic cough.	Intermediate Low	Strong Strong
C24	What is the suggested treatment for a child diagnosed as somatic cough disorder?	ACCP 2020	Non-pharmacological trials of hypnosis or Suggestion therapy or Reassurance and counseling or Referral to a psychologist or psychiatrist.	Low	Strong
C25	For children suspected for having OSA, what is the management?	ACCP 2020	They are managed in according to sleep guidelines.	Very low	Weak (conditional)
C26	Should histamine H1-receptor antagonists (H1RAs) be used to treat non-specific chronic cough?	Korean 2019	The use of H1RAs in children with non-specific cough must be balanced against the well-known adverse events, especially in very young children ACCP recommended against the empirical use of H1RAs in children with chronic cough, unless other features consistent with upper airways cough syndrome due to rhinosinusitis are present.	Low	Weak (Conditional) Good practice statement Chang et al, 2017 (41)
C27	Should LTRAs be used to treat non-specific chronic cough?	Korean 2019	Careful considerations of cost, risk and benefits are needed until there is sufficient data to determine the efficacy of LTRAs in these children.	Very low	Weak (Conditional)
C28	Should neuromodulators (opioids, gabapentin or pregabalin,) be used?		Cough neuromodulators, are not used in children due to reported adverse events, possible toxicity and lack of clinical trials.		Good practice statement Gardiner et al., 2016 (42)