Chronic cough in children (Paediatric Guidelines)

Persistent bacterial bronchitis (PBB)

• Defined as: A continuous chronic wet / productive cough (>4 weeks) without any signs / symptoms suggestive of other causes of wet / productive cough that resolves with 2 to 4 weeks antibiotics
• Almost exclusive to children between 1 to 6 years age
• Obtain sputum culture before antibiotics if possible, in older children
• A trial of 2 weeks co-amoxiclav is advised if PBB suspected
• Do not prescribe repeated courses of antibiotics for PBB, refer if concern of recurrence of PBB (can be a precursor to bronchiectasis)

Asthma

• Cough variant asthma is rare in children; Asthma diagnosis is unlikely if there is no history of recurrent wheeze episodes
• Consider asthma if presence of potential triggers, seasonal variation, diurnal variation, family / personal history of atopy
• Refer to asthma guidelines for investigation/treatment

Inhaled foreign body

• A possibility in any sudden-onset cough in otherwise healthy pre-school child
• Examination may reveal persistent focal signs

Gastro-oesophageal reflux (GORD)

• Consider if there is a clinical history suggestive of reflux
• Do not routinely offer anti-acid therapy for chronic cough with no other features of GORD

Postnasal drip

• Often presents with family/personal history of atopy and persistent nasal congestion
• Consider trial of antihistamine therapy if suspected as cause for chronic cough
• Intranasal steroids and saline drops can also be useful

Sinister pathologies

• Eg Cystic fibrosis, TB, immune deficiency syndromes, etc. May present in a wide variety of manners
• Refer if there is a clinical concern

Habit cough (somatic cough syndrome)

• A diagnosis of exclusion
• Typically presents as a cough with a high degree of variability, distractibility

Is this a recurrent cough or a chronic cough?

• Viral infections are the commonest cause of cough in children (7 to 10 infections/year, often clustered during Winter is normal in school age children)
• Ask, has the child coughed every day, or has the cough improved at times, then deteriorated
• Children with recurrent viral coughs can generally be reassured, as long as no other concerns re. growth / systemic features

Is the cough wet or dry?

• This can be difficult to assess, but the nature of the cough may give important clues as to the underlying cause (wet cough more likely secondary to persistent bacterial bronchitis)
• If the child is not coughing during assessment, it may be helpful to ask the parent to try and capture a video of any coughing episodes

Important considerations in history/exam

• Cough duration and severity/impact
• Possible triggers? (pets / smoke / pollution / pollen / mould, etc.)
• Associated symptoms (sore throat, chest pain / reflux, rhinitis / postnasal drip / nasal congestion)
• Perform throat exam, chest auscultation and otoscopy at a minimum in all children with chronic cough

Antibiotic choice: 

• Co-amoxiclav. Duration: 2 weeks
• OR, if allergic: clarithromycin or azithromycin

Further information regarding length of treatment course and antibiotic choice can be found here: 

• ERS statement on protracted bacterial bronchitis in children | European Respiratory Society
• Protracted bacterial bronchitis (PBB) | Blog entry by _ RCGP Learning | RCGP Learning

• CF - cystic fibrosis
• CXR - chest xray
• PBB - persistent bacterial bronchitis
• PCD - primary ciliary dyskinesia
• TB - tuberculosis