What are management options for chronic cough in children?

LITERATURE REVIEW The differential diagnosis for CC in children is quite extensive. In general, specific CC has a known etiology, whereas nonspecific CC has no clear identifiable etiology. Treatment of specific cough can be tailored to the diagnosis; however, management becomes increasingly challenging when there is nonspecific cough. An algorithm has been proposed for management of CC in children. Essentially, if there are no signs of severe illness (cardiac abnormalities, tachypnea, digital clubbing, chest deformity, failure to thrive, hypoxia, cyanosis, aspiration, etc.) and the cough is not characteristic of specific illness (staccato cough in chlamydia, paroxysmal cough in pertussis, etc.), then watchful waiting is recommended. The algorithm calls to evaluate for environmental exposures and association of cough with specific activities, and to address parental concerns. If cough persists or if signs of a more severe illness emerge, then CC can be divided into wet cough or dry cough. It is recommended in the algorithm to treat dry cough with inhaled steroids and chronic wet cough (likely protracted bacterial bronchitis [PBB]) with at least 2 to 6 weeks of antibiotics (Fig. 1). There is evidence that shows antibiotic treatment is effective for children with PBB. Amoxicillin-clavulanate has been shown to significantly reduce the proportion of patients who are not cured and reduce progression of illness. A multicenter randomized clinical trial studied early versus late application of this algorithm for evaluation and treatment of CC in children. Application of this algorithm led to significantly improved outcomes whether implemented early or late in the treatment of cough. If CC does not respond or there are signs of severe illness, pulmonary consultation is advised. Pulmonary consultation will allow evaluation for chronic disorders such as ciliary dyskinesia, interstitial lung disease, and atypical infections such as mycoplasma or tuberculosis. In addition, appropriate diagnostic studies with bronchoscopy, lavage, ciliary biopsy, and other tests can be completed expeditiously as indicated. Early pulmonary consult in cases of nonresolution or cases with signs of more severe illness will prevent a delay in diagnosis. Habit or psychogenic cough is deserving of mention in particular because this is a diagnosis of exclusion. Habit cough is diagnosed when there is no detectable physiologic etiology, cough is limited to wakefulness with normal physical exams, and tic disorders have been excluded. In patients with this particular diagnosis, treatment is behavior modification or psychiatric therapy. Numerous other medications have not been shown to be efficacious, however. Use of over-the-counter medications is not supported by the American Academy of Pediatrics or the American College of Chest Physicians. A Cochrane review of CC in children found that treatment for GERD or that treatment with anticholinergics, antihistamines, inhaled cromones, leukotriene receptor antagonist, inhaled corticosteroids, beta-2 agonists, and methylxanthines, showed no benefit—or that existing studies are inadequate to make recommendations. Only honey was shown to be effective for symptomatic relief of CC. The placebo effect was shown to be powerful with CC, and some cases can resolve spontaneously. Parents often ascribe resolution to medication or placebo. Addressing parental concerns over lost sleep, possible lung damage, or possible serious illness is important because this influences the rates of prescription medication and consultations. Education about avoidance of environmental exposures (smoking, wood fire, etc.) is also highly effective.