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Suspected resp tract infxn Upper | Coryza sx w/o chest s/sx Consider COVID-19 (wet or dry cough) or flu. Most are viral; abx not warranted except for pertussis, Group A strep, certain acute bacterial rhinosinusitis, etc - Abx not recommended for URI unless criteria for acute bacterial rhinosinusitis (>10 days, worsening, or severe)1-3 or Group A strep pharyngitis1 met, per AAP.4 If clinical picture strongly suggests pertussis,5 strongly consider tx while awaiting test results, per CDC1
- Honey may offer sx relief (avoid if <1 yo)6
- Don’t use OTC cough/cold meds.1,6 Not recommended for young children, per AAP,4 FDA;7 of no proven benefit in children <6 yo, per CDC.1 Insufficient evidence on expectorants, antihistamines, mucolytics, or combos, per ACCP6
- Don’t use: codeine6,8,9/hydrocodone.9 Insufficient evidence on acetylcysteine, carbocysteine.6 Low-dose inhaled steroids, PO prednisolone don’t improve outcomes in pts w/o asthma1
- Educate on natural hx of cough, s/sx warranting re-eval
Footnotes 1 CDC 2017. Appropriate Antibiotic Use: Community. Pediatric Treatment Recommendations. Reviewed 2/01/17. Accessed 9/22/20
Acute sinusitis
• Hx/Ex: halitosis, fatigue, HA, ↓appetite; exam doesn’t distinguish bacterial from viral.
• Dx: bacterial dx=any of these: 1) Persistent sx w/o improvement: nasal d/c or daytime cough >10 days. 2) Worsening sx: worsening or new-onset fever, daytime cough, or nasal d/c after initial improvement of viral URI. 3) Severe sx: fever ≥39°C, purulent nasal d/c ≥3 consecutive days.
• Imaging no longer recommended for uncomplicated cases.
• Tx: Abx not guaranteed to help even if bacterial. If persistent sx, may offer watchful waiting up to 3 days. Use abx for severe/worsening ABRS; 1st-line: amoxicillin or amoxicillin/clavulanate; if unable to take PO, 1 dose ceftriaxone, then switch to PO when improving.
Common cold/nonspecific URI
• Viral: nasal d/c (starts clear then changes), congestion, cough; fever, if present, is early in illness.
• Course of viral URIs ~5–7 days; colds usually last ~10 days.
• OTC cough/cold drugs: potential for harm, no proven benefit in children <6 yo.
• Low-dose inhaled steroids, PO prednisolone don’t improve outcomes in pts w/o asthma.
Strep pharyngitis
Primarily in 5-15 yo; rare in <3 yo. Use RADT if sore throat + ≥2 of: cough absence, tonsil exudates/swelling, fever, swollen tender anterior cervical LN, <15 yo. False (+): In winter, spring, up to 20% children w/o sx may be colonized; (-) RADT warrants throat Cx, (+) RADT doesn’t.
2 AAP 2013. Wald ER, et al; American Academy of Pediatrics. Clinical Practice Guideline for the Diagnosis and Management of Acute Bacterial Sinusitis in Children Aged 1 to 18 Years. Pediatrics. 2013 Jul;132(1):e262-80. PubMed® abstract
ABRS defined as any of:
1) nasal d/c (any quality) &/or daytime cough (may be worse at night) >10 days w/o improving, or
2) severe initial s/sx of T ≥102.2°F + purulent d/c x ≥3 days, or
3) worsening after initial improvement (eg, new-onset fever &/or ↑daytime cough, nasal d/c or congestion). Acute is <30 days.
3 IDSA 2012. Chow AW, et al. IDSA Clinical Practice Guideline for Acute Bacterial Rhinosinusitis in Children and Adults. Clin Infect Dis. 2012 Apr;54(8):e72-e112. PubMed® abstract | Accessed 9/22/20
ABRS dx based on persistent s/sx, severe initial s/sx, or worsening after initial improvement (ie, double sickening, defined as new fever, HA, ↑nasal d/c after 5-6 days of improving viral URI). Acute is ≤4wk of s/sx: nasal d/c (any quality), daytime cough (may be worse at night), fever are common; but HA, facial pain, swelling rare in children.
4 AAP 2018. Choosing Wisely. American Academy of Pediatrics. Updated 6/12/18.
• Don’t use abx for URI (eg, congestion, cough, pharyngeal pain/pharyngitis, sinusitis, bronchitis, bronchiolitis) unless criteria met for bacterial sinusitis or Group A strep pharyngitis.
• Don't prescribe/recommend cough/cold meds for resp illness in young children. Research shows little benefit despite serious side-effect potential. Multi-ingredient products pose OD risk if combined w/ other products.
5 CDC 2019. Pertussis (Whooping Cough). Centers for Disease Control and Prevention. Reviewed 10/25/19. Accessed 9/22/20
• Test: nasopharyngeal swab or aspirate for PCR, cx; special handling required.
• Stage 1 Catarrhal: Insidious sx onset w/in 5-10 days of exposure (max 21 days). Coryza, low-grade fever, initially intermittent mild cough gradually increases in severity.
• Stage 2 Paroxysmal: Cough persists x1-6wk. Multiple paroxysms of numerous rapid coughs (often at night) ending in whoop, thick mucus, posttussive emesis, long inspiratory effort, cyanosis, exhaustion. Whoop, emesis may be absent. Paroxysms disappear in 2-3wk.
• Stage 3 Convalescent: Nonparoxysmal cough may persist 2-6wk after paroxysms subside, though paroxysms may recur months later.
6 ACCP 2017. Malesker MA, et al. Pharmacologic and Nonpharmacologic Treatment for Acute Cough Associated With the Common Cold: CHEST Expert Panel Report. American College of Chest Physicians. Chest. 2017 Nov;152(5):1021-1037. PubMed®abstract | Free full-text article PDF @ PubMed® Central
• Insufficient evidence on OTC antitussives, incl expectorants, antihistamines, mucolytics, or combos.
• Honey. In pts 1-18 yo, honey may improve cough vs placebo or diphenhydramine, but not better than dextromethorphan. Avoid if <1 yo.
• Dextromethorphan. Avoid if <2 yo.
• Acetylcysteine, carbocysteine; zinc prophylaxis: unable to make recommendations.
7 FDA 2008. OTC Cough and Cold Products: Not For Infants and Children Under 2 Years of Age. Issued 1/17/08.
8 ERS 2020. Morice AH, et al. ERS Guidelines on the Diagnosis and Treatment of Chronic Cough in Adults and Children. Eur Respir J. 2020 Jan 2;55(1):1901136. PubMed® abstract | Free full-text article PDF @ PubMed®Central
9 FDA 2018. FDA Drug Safety Communication: FDA Requires Labeling Changes for Prescription Opioid Cough and Cold Medicines to Limit Their Use to Adults 18 Years and Older. Issued 1/11/18. Accessed 9/20/20
Lower | Chest signs (eg, crackles, wheezes, retrxn), fever, tachypnea, resp distress Consider COVID-19 (wet or dry cough), flu; viral or bacterial pneumonia, viral triggering of asthma, pertussis, etc. Don’t use abx for acute bronchitis/bronchiolitis, per AAP;1,2 If clinical picture strongly suggests pertussis,3 strongly consider tx awaiting test results, per CDC. Don’t use OTC cough meds,4,5 (for young children, per AAP,1 FDA6) - Bronchiolitis (<2 yo wintertime post-URI w/ ↑RR, wheeze, &/or crepitation/crackles):2,7,8 cough self-limiting (90% resolves ≤21 days).7 Nasal (not deep) suctioning is mainstay. Don’t use abx8 (unless concomitant bacterial infxn known/strongly suspected, per AAP2), systemic steroids, chest PT, albuterol, salbutamol, epinephrine NEB, per AAP,2 CDC.8 Don’t use ribavirin.8 Hypertonic saline not used in ED, but weak recommendation for inpt, per AAP2
- Cough sx relief: Honey may help cough (avoid if <1 yo).4 Don’t use OTC cough meds4,5 for young children, per AAP,1 FDA6 no proven benefit in children <6 yo, per CDC.8 Insufficient evidence on expectorants, antihistamines, mucolytics, or combos, per ACCP.9 Don’t use codeine4,5,10/hydrocodone.10 Insufficient evidence on acetylcysteine, carbocysteine4
Footnotes 1 AAP 2018. Choosing Wisely. American Academy of Pediatrics. Updated 6/12/18.
• Don’t prescribe/recommend cough/cold meds for resp illness in young children. Research shows little benefit despite serious side-effect potential. Multi-ingredient products pose OD risk if combined w/ other products.
• Don’t use abx for URI (eg, congestion, cough, pharyngeal pain/pharyngitis, sinusitis, bronchitis, bronchiolitis) unless criteria met for bacterial sinusitis or Group A strep pharyngitis.
2 AAP 2014. Ralston SL, et al. Clinical Practice Guideline: The Diagnosis, Management, and Prevention of Bronchiolitis. American Academy of Pediatrics. Pediatrics. 2014 Nov;134(5):e1474-502.
PubMed® abstract | Free full-text Pediatrics article PDF
• Clinical dx: <2 yo w/ viral upper resp prodrome, rhinorrhea, cough, tachypnea, wheeze, rales, ↑resp effort (grunt, nasal flaring, intercostal/subcostal retrxn). Clinical dx doesn’t routinely require lab, imaging
• Don’t give albuterol, salbutamol, epinephrine, systemic steroids, or use chest PT for bronchiolitis.
• Don’t use antibacterials unless concomitant bacterial infxn known/strongly suspected.
• Nebulized hypertonic saline: Don’t give in ED (mod recommendation) but may use for inpt (weak recommendation).
3 CDC 2019. Pertussis (Whooping Cough). Centers for Disease Control and Prevention. Reviewed 10/25/19. Accessed 9/22/20
• Test: nasopharyngeal swab or aspirate for PCR, cx; special handling required.
• Stage 1 Catarrhal: Insidious sx onset w/in 5-10 days of exposure (max 21 days). Coryza, low-grade fever, initially intermittent mild cough gradually increases in severity.
• Stage 2 Paroxysmal: Cough persists x1-6wk. Multiple paroxysms of numerous rapid coughs (often at night) ending in whoop, thick mucus, posttussive emesis, long inspiratory effort, cyanosis, exhaustion. Whoop, emesis may be absent. Paroxysms disappear in 2-3wk.
• Stage 3 Convalescent: Nonparoxysmal cough may persist 2-6wk after paroxysms subside, though paroxysms may recur months later.
4 ACCP 2020. Chang AB, et al. Managing Chronic Cough as a Symptom in Children and Management Algorithms: CHEST Guideline and Expert Panel Report. American College of Chest Physicians. Chest. 2020 Jul;158(1):303-329. PubMed®abstract | Free full-text Chest article PDF
5 ERS 2020. Morice AH, et al. ERS Guidelines on the Diagnosis and Treatment of Chronic Cough in Adults and Children. Eur Respir J. 2020 Jan 2;55(1):1901136. PubMed® abstract | Free full-text article PDF @ PubMed®Central
6 FDA 2008. OTC Cough and Cold Products: Not For Infants and Children Under 2 Years of Age. Issued 1/17/08.
7 ACCP 2018. Chang AB, et al. Chronic Cough Related to Acute Viral Bronchiolitis in Children: CHEST Expert Panel Report. American College of Chest Physicians. Chest. 2018 Aug;154(2):378-382. PubMed®abstract | Free full-text article PDF @ PubMed® Central
8 CDC 2017. Appropriate Antibiotic Use: Community. Pediatric Treatment Recommendations. Reviewed 2/01/17. Accessed 9/22/20
Bronchiolitis
• Sx: rhinorrhea, cough, wheezing, tachypnea, &/or increased resp effort. Usually worsens @ 3-5 days, then improves.
• Tests: Routine labs, imaging not recommended; CXR may be warranted in atypical dz (eg, no viral symptoms, severe distress, freq recurrences, lack of improvement).
• Tx: Nasal suctioning is mainstay; no evidence supports deep suctioning. Don’t use abx. Neither albuterol nor nebulized racemic epinephrine should be given to bronchiolitis outpts. No role for steroids, ribavirin, or chest PT.
9 ACCP 2017. Malesker MA, et al. Pharmacologic and Nonpharmacologic Treatment for Acute Cough Associated With the Common Cold: CHEST Expert Panel Report. American College of Chest Physicians. Chest. 2017 Nov;152(5):1021-1037. PubMed® abstract | Free full-text article PDF @ PubMed® Central
• Insufficient evidence on OTC antitussives, including expectorants, antihistamines, mucolytics, or combos.
• Honey. In pts 1-18 yo, honey may improve cough vs placebo or diphenhydramine, but not better than dextromethorphan. Avoid if <1 yo.
• Dextromethorphan. Avoid if <2 yo.
• Acetylcysteine, carbocysteine; zinc prophylaxis: unable to make recommendations.
10 FDA 2018. FDA Drug Safety Communication: FDA Requires Labeling Changes for Prescription Opioid Cough and Cold Medicines to Limit Their Use to Adults 18 Years and Older. Issued 1/11/18. Accessed 9/20/20
No suspicion of resp tract infxn Suspect inhaled foreign body | Sudden onset, witnessed choking, asymmetrical wheeze, ↓breath sounds, or hyperinflation
Urgent rigid bronchoscopy for inhaled FB - Lack of aspiration hx doesn’t r/o FB, as episode may have been unwitnessed1
- Normal CXR doesn’t exclude inhaled FB1
- Urgent rigid bronchoscopy indicated on hx alone to dx, remove FB, per BTS2
No suspicion of inhaled foreign body Consider COVID-19 (wet or dry cough), flu, allergic rhinitis, asthma, based on s/sx. Don’t use OTC cough meds,1,2 (for young children, per AAP,3 FDA4) - Allergic rhinitis: sneezing, nasal congestion, rhinorrhea, itchy nose/throat/palate, postnasal drip, throat clearing, cough, malaise, fatigue5
- Asthma: wheeze assoc w/ cough. NL spirometry doesn’t r/o asthma.1 However, bronchodilators not effective in nonasthmatic pts6
- Pertussis: Classic whoop, posttussive emesis may be absent in older pts. If clinical picture strongly suggestive, strongly consider tx while awaiting test results, per CDC7
- Honey may offer sx relief (avoid if <1 yo)1
- Don’t use OTC cough/cold meds.1,2,8 Not recommended for young children, per AAP,3 FDA;4 of no proven benefit in children <6 yo, per CDC.8 Insufficient evidence on expectorants, antihistamines, mucolytics, or combos, per ACCP1
- Don’t use: codeine1,2,9/hydrocodone9
Footnotes 1 ACCP 2020. Chang AB, et al. Managing Chronic Cough as a Symptom in Children and Management Algorithms: CHEST Guideline and Expert Panel Report. American College of Chest Physicians. Chest. 2020 Jul;158(1):303-329. PubMed® abstract | Free full-text Chest article PDF
2 ERS 2020. Morice AH, et al. ERS Guidelines on the Diagnosis and Treatment of Chronic Cough in Adults and Children. Eur Respir J. 2020 Jan 2;55(1):1901136. PubMed® abstract | Free full-text article PDF @ PubMed®Central
3 AAP 2018. Choosing Wisely. American Academy of Pediatrics. Updated 6/12/18.
• Don’t prescribe/recommend cough/cold meds for resp illness in young children. Research shows little benefit despite serious side-effect potential. Multi-ingredient products pose OD risk if combined w/ other products.
4 FDA 2008. OTC Cough and Cold Products: Not For Infants and Children Under 2 Years of Age. Issued 1/17/08.
5 AAO 2015. Seidman MD, et al. Clinical Practice Guideline: Allergic Rhinitis. Otolaryngol Head Neck Surg. 2015 Feb;152(1 Suppl):S1-43. PubMed® abstract | Free full-text Otolaryngol Head Neck Surg article PDF
6 BTS 2008. Shields MD, et al. BTS Guidelines: Recommendations for the Assessment and Management of Cough in Children. Thorax. 2008 Apr;63(Suppl 3):iii1-iii15. PubMed® abstract | Free full-text Thorax article PDF
7 CDC 2019. Pertussis (Whooping Cough). Centers for Disease Control and Prevention. Reviewed 10/25/19. Accessed 9/22/20
• Test: nasopharyngeal swab or aspirate for PCR, cx; special handling required.
• Stage 1 Catarrhal: Insidious sx onset w/in 5-10 days of exposure (max 21 days). Coryza, low-grade fever, initially intermittent mild cough gradually increases in severity.
• Stage 2 Paroxysmal: Cough persists x1-6wk. Multiple paroxysms of numerous rapid coughs (often at night) ending in whoop, thick mucus, posttussive emesis, long inspiratory effort, cyanosis, exhaustion. Whoop, emesis may be absent. Paroxysms disappear in 2-3wk.
• Stage 3 Convalescent: Nonparoxysmal cough may persist 2-6wk after paroxysms subside, though paroxysms may recur months later.
8 CDC 2017. Appropriate Antibiotic Use: Community. Pediatric Treatment Recommendations. Reviewed 2/01/17. Accessed 9/22/20
• OTC cough/cold drugs: potential for harm, no proven benefit in children <6 yo.
9 FDA 2018. FDA Drug Safety Communication: FDA Requires Labeling Changes for Prescription Opioid Cough and Cold Medicines to Limit Their Use to Adults 18 Years and Older. Issued 1/11/18. Accessed 9/20/20
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Specific-cough s/sx: wet/productive, classic sound/type, choking hx, SOB, chest pain, sinus sx; feeding/growth/development issues, chronic lung/esophagus dz, recurrent infxn; or abnl exam/test Consider COVID-19. ✓CXR, ✓spirometry1,2 (3-6+ yo).1 If wet cough w/o other specific pointers1 from hx/exam/test, cough sound/type, triggers:2 tx as protracted bacterial bronchitis.1,2 If other pointers present: pedi pulm referral &/or DDx eval.1,2 For all: ✓tobacco smoke/pollutants, child activity level, parental concerns1 If wet cough w/o other specific-cough pointers:1 - Treat as protracted bacterial bronchitis:2 2wk of abx; re-eval in 2wk until resolved1
- If wet cough not resolving after 2wks: Repeat another 2-wk course & re-eval in 2wk1
- If wet cough persists after 4wk of abx: Refer to pedi pulm &/or eval2 (eg, bronch) for DDx1 (atypical/recurrent infxn, TB, panbronchiolitis, CF/bronchiectasis,3 recurrent aspiration, etc)1
If other specific-cough pointers1 beyond wet cough, eval & tx specific dx (eg, meds for asthma, airway clearance technique for bronchiectasis,3 etc): - Test for pertussis4 if suspected (posttussive vomit, paroxysms, inspiratory whoop)1
- Don’t routinely allergy test w/o s/sx allergies;2 however, may help if dx uncertain or for allergy sx mgmt, per AAO5
- Refer to pedi pulm &/or eval DDx1 (atypical/recurrent infxn, TB, panbronchiolitis, bronchiectasis/ suppurative lung dz, recurrent aspiration, etc)1
- Don’t empirically tx UACS/postnasal drip from sinus dz (controversial pedi cause), GERD (rare pedi cause6), or asthma unless clinical features beyond cough present.1 Set time limit on tx trials.1 Post-acute viral bronchiolitis cough: Don’t use asthma drugs (unless wheeze/SOB/other asthma s/sx) or inhaled osmotic agents7
- Don’t use OTC cough meds1,2 for young children, per AAP,8 FDA;9 no proven benefit in pt <6 yo, per CDC.10 Honey may help cough (avoid if <1 yo).1 Don’t use codeine1,2,11
Footnotes 1 ACCP 2020. Chang AB, et al. Managing Chronic Cough as a Symptom in Children and Management Algorithms: CHEST Guideline and Expert Panel Report. American College of Chest Physicians. Chest. 2020 Jul;158(1):303-329. PubMed® abstract | Free full-text Chest article PDF
Specific cough pointers:
• Cough sound/type: bark/brassy (croup, tracheomalacia, habit/tic); honking (habit/tic); paroxysmal +/- whoop (pertussis, parapertussis); staccato (infant chlamydia); coughing casts (plastic bronchitis); habit/tic cough can occur at nighttime.
• Hx: choking, chest pain, SOB/exertional dyspnea, face pain, purulent nasal d/c, hemoptysis, recurrent infxns/pneumonia, hx chronic lung/esophagus dz, feeding difficulty, growth/neurodevelopment issues
• Exam: ↑RR, wheeze (monophonic: FB, abnl anatomy; polyphonic: asthma, bronchiolitis, etc), crepitation, abnl cardiac exam, chest wall deformity, clubbing, cyanosis, face tenderness, purulent nasal d/c, hoarse voice/stridor
• Tests: hypoxia, abnl spirometry or CXR
Spirometry (pre-/post- beta-2 agonist)
• Doable for >6 yo (possible for >3 yo if pedi-trained staff present).
• If NL, doesn’t r/o asthma.
• Airway hyperresponsiveness may be temporary post-infxn or w/ allergic rhinitis; may not predict later asthma or asthma med response.
• FeNO: Role undefined in children w/o classic asthma sx.
Abx for wet cough: Target S pneumoniae, H flu, M catarrhalis, per local abx susceptibilities.
DDx, eval for specific cough & persistent cough
• Bronchiectasis/recurrent pneumonia (immunodeficiency, CF, FB, structural airway dz, congenital lesion, TEF/H-fistula, etc): sweat test, bronch, immune w/u, chest CT, Ba swallow, genetics
• Infxn (TB, non-TB mycobacteria, mycosis, parasites, etc): sputum/blood tests, bronch + lavage, CT chest
• Aspiration (abnl swallow/cough reflex, neuromuscular dz, larynx issue, tonsil/adenoid hypertrophy, severe GERD, TEF/H-fistula, etc): Ba swallow, bronch + lavage, video fluoro, pH meter, lung milk scan/salivagram
• Interstitial lung dz (drug/XRT effects, rheum dz): serum markers, HRCT, lung bx, genetics
• Abnl airway (tracheomalacia, extrinsic compression, etc): bronch + lavage, CT chest, MRI chest
• Cardiac dz (pulm HTN, cardiac edema): pedi cardiology referral, ECG, echo, cardiac cath
• Drug effect (eg, ACEI, immediately post-inhalation of asthma inhaler, new tic cough from dextroamphetamine, etanercept)
• Other pulm dz (pulm edema, tumor, etc)
2 ERS 2020. Morice AH, et al. ERS Guidelines on the Diagnosis and Treatment of Chronic Cough in Adults and Children. Eur Respir J. 2020 Jan 2;55(1):1901136. PubMed® abstract | Free full-text article PDF @ PubMed® Central
• Protracted bacterial bronchitis=continuous wet/productive cough >4wk, w/o specific-cough s/sx pointers that suggest other conditions, which resolves after 2-4wk of oral abx.
• Cough triggers: indoor/outdoor irritants: cold air, perfume, smoke, traffic emissions, bleach
3 ACCP 2018. Hill AT, et al. Treating Cough Due to Non-CF and CF Bronchiectasis With Nonpharmacological Airway Clearance: CHEST Expert Panel Report. American College of Chest Physicians. Chest. 2018 Apr;153(4):986-993. PubMed® abstract | Free full-text Chest article PDF @ PubMed® Central
4 CDC 2019. Pertussis (Whooping Cough). Centers for Disease Control and Prevention. Reviewed 10/25/19. Accessed 9/22/20
• Test: nasopharyngeal swab or aspirate for PCR, cx; special handling required.
• Stage 1 Catarrhal: Insidious sx onset w/in 5-10 days of exposure (max 21 days). Coryza, low-grade fever, initially intermittent mild cough gradually increases in severity.
• Stage 2 Paroxysmal: Cough persists x1-6wk. Multiple paroxysms of numerous rapid coughs (often at night) ending in whoop, thick mucus, posttussive emesis, long inspiratory effort, cyanosis, exhaustion. Whoop, emesis may be absent. Paroxysms disappear in 2-3wk.
• Stage 3 Convalescent: Nonparoxysmal cough may persist 2-6wk after paroxysms subside, though paroxysms may recur months later.
5 AAO 2015. Seidman MD, et al. Clinical Practice Guideline: Allergic Rhinitis. Otolaryngol Head Neck Surg. 2015 Feb;152(1 Suppl):S1-43. PubMed® abstract | Free full-text Otolaryngol Head Neck Surg article PDF
6 ACCP 2019. Chang AB, et al. Chronic Cough and Gastroesophageal Reflux in Children: CHEST Guideline and Expert Panel Report. American College of Chest Physicians. Chest. 2019 Jul;156(1):131-140. PubMed® abstract | Free full-text Chest article PDF @ PubMed® Central
GERD not common as pedi chronic cough etiology. Don’t empirically tx GERD w/o clinical features (recurrent regurgitation, infant dystonic neck posturing, heartburn/epigastric pain). In pts w/ consistent s/sx/tests for GERD: Don’t use acid suppression tx solely for chronic cough. If PPI/H2RA used as tx trials: Re-eval @4-8wk.
7 ACCP 2018. Chang AB, et al. Chronic Cough Related to Acute Viral Bronchiolitis in Children: CHEST Expert Panel Report. American College of Chest Physicians. Chest. 2018 Aug;154(2):378-382. PubMed® abstract | Free full-text article PDF @ PubMed® Central
8 AAP 2018. Choosing Wisely. American Academy of Pediatrics. Updated 6/12/18.
• Don’t prescribe/recommend cough/cold meds for resp illness in young children. Research shows little benefit despite serious side-effect potential. Multi-ingredient products pose OD risk if combined w/ other products.
9 FDA 2008. OTC Cough and Cold Products: Not For Infants and Children Under 2 Years of Age. Issued 1/17/08.
10 CDC 2017. Appropriate Antibiotic Use: Community. Pediatric Treatment Recommendations. Reviewed 2/01/17. Accessed 9/22/20
OTC cough/cold drugs: potential for harm, no proven benefit in children <6 yo.
11 FDA 2018. FDA Drug Safety Communication: FDA Requires Labeling Changes for Prescription Opioid Cough and Cold Medicines to Limit Their Use to Adults 18 Years and Older. Issued 1/11/18. Accessed 9/20/20
Consider COVID-19. ✓CXR, ✓spirometry1,2 (3-6+ yo),1 factor asthma s/sx & other pointers from hx/exam, cough sound/type,1 triggers.2 Most children w/ isolated cough (incl nocturnal) don’t have asthma. ✓Tobacco smoke/pollutants, child activity level, parental concerns1
If asthma/reversible airway obstruction, re-eval in 2-4wk for persistence.1 Wheeze shouldn’t r/o pertussis3 (test if suspected). At re-eval: - If wet cough has developed, re-eval for new DDx1
- If dry cough persists, pedi pulm referral &/or eval for underlying dz DDx1 (bronchiectasis, TB/mycosis/other infxn, immunodeficiency, aspiration, interstitial lung dz, abnl airway, cardiac dz, habit/tic, etc)1
If no asthma/reversible airway obstruction, consider pedi pulm consult and/or eval2 for underlying dz:1 - DDx: Post-viral URI most common; sequential viral URIs may occur. Consider bronchiectasis, TB/mycosis/other infxn, immunodeficiency, aspiration, interstitial lung dz, abnl airway, cardiac dz, drug effect, habit/tic, etc1
- Test for pertussis if suspected (posttussive vomit, paroxysms, inspiratory whoop)3
- Don’t routinely allergy test w/o s/sx allergies;1,2 however, testing may be useful if dx uncertain or for allergy mgmt, per AAO4
- Don’t empirically tx UACS/postnasal drip from sinus dz (controversial pedi cause), GERD (rare pedi cause5), or asthma unless clinical features beyond cough present.1 Set time limit on tx trials.1 Post-acute viral bronchiolitis cough: Don’t use asthma drugs (unless wheeze/SOB/other asthma s/sx)6 or inhaled osmotic agents6
- Don’t use OTC cough meds (in young children, per AAP,7 FDA8), d/t adverse event risk, insufficient evidence of benefit;1 no proven benefit in pts <6 yo, per CDC.9 Honey may help cough (avoid if <1 yo).1 Don’t use codeine,1,2,10 hydrocodone,10 gabapentin, or pregabalin in children.2 Insufficient evidence on PPIs or antileukotrienes in children, per ERS2
- Therapy for somatic cough disorder11,12 (aka, habit/tic/psychogenic) lacks evidence in children.2 Reassurance, psychotherapy, counseling, suggestion tx, hypnosis, etc, have been suggested2
Footnotes 1 ACCP 2020. Chang AB, et al. Managing Chronic Cough as a Symptom in Children and Management Algorithms: CHEST Guideline and Expert Panel Report. American College of Chest Physicians. Chest. 2020 Jul;158(1):303-329. PubMed® abstract | Free full-text Chest article PDF
Specific cough pointers:
• Cough sound/type: bark/brassy, honking, paroxysmal (+/- whoop), staccato, coughing up casts; habit/tic cough can be barking/honking/occur at nighttime.
• Hx: choking, chest pain, SOB/exertional dyspnea, face pain, purulent nasal d/c, hemoptysis, recurrent infxns, chronic lung/esophagus dz, feeding difficulty, growth/neurodevelopment issues
• Exam: ↑RR, wheeze, crepitation, abnl CV/chest wall exam, clubbing, cyanosis, face tender, purulent nasal d/c, hoarse/stridor
• Tests: abnl spirometry/O 2/CXR
Spirometry (pre-/post- beta-2 agonist)
• Doable for >6 yo (possible for >3 yo if pedi-trained staff present).
• If NL, doesn’t r/o asthma.
• Airway hyperresponsiveness may be temporary post-infxn or w/ allergic rhinitis; may not predict later asthma or asthma med response.
• FeNO: Role undefined in children w/o classic asthma sx.
DDx, eval for persistent cough
• Bronchiectasis/recurrent pneumonia (immunodeficiency, CF, FB, structural airway dz, congenital lesion, TEF/H-fistula, etc): sweat test, bronch, immune w/u, chest CT, Ba swallow, genetics
• Infxn (TB, non-TB mycobacteria, mycosis, parasites, etc): sputum/blood tests, bronch + lavage, CT chest
• Aspiration (abnl swallow/cough reflex, neuromuscular dz, larynx issue, tonsil/adenoid hypertrophy, severe GERD, TEF/H-fistula, etc): Ba swallow, bronch + lavage, video fluoro, pH meter, lung milk scan/salivagram
• Interstitial lung dz (drug/XRT effects, rheum dz): serum markers, HRCT, lung bx, genetics
• Abnl airway (tracheomalacia, extrinsic compression, etc): bronch + lavage, CT chest, MRI chest
• Cardiac dz (pulm HTN , cardiac edema): pedi cardiology referral, ECG, echo, cardiac cath
• Other pulm dz (sleep apnea, pulm edema, tumor, etc)
• Drug effect (eg, ACEI, immediately post-inhalation of asthma inhaler, new tic cough from dextroamphetamine, etanercept)
• Otogenic: ear-cough reflex. Vagal nerve activation by foreign matter/hair on eardrum
• Somatic cough syndrome (formerly habit/tic/psychogenic cough). Unexplained cough after comprehensive eval. Features: cough suppressibility, distractibility, suggestibility, variability, premonitory sense of single vs multiple tics
2 ERS 2020. Morice AH, et al. ERS Guidelines on the Diagnosis and Treatment of Chronic Cough in Adults and Children. Eur Respir J. 2020 Jan 2;55(1):1901136. PubMed® abstract | Free full-text article PDF @ PubMed® Central
Triggers: indoor/outdoor irritants: cold air, perfume, smoke, traffic emissions, bleach, etc
3 CDC 2019. Pertussis (Whooping Cough). Centers for Disease Control and Prevention. Reviewed 10/25/19. Accessed 9/22/20
• Test: nasopharyngeal swab or aspirate for PCR, cx; special handling required.
• Stage 1 Catarrhal: Insidious sx onset w/in 5-10 days of exposure (max 21 days). Coryza, low-grade fever, initially intermittent mild cough gradually increases in severity.
• Stage 2 Paroxysmal: Cough persists x1-6wk. Multiple paroxysms of numerous rapid coughs (often at night) ending in whoop, thick mucus, posttussive emesis, long inspiratory effort, cyanosis, exhaustion. Whoop, emesis may be absent. Paroxysms disappear in 2-3wk.
• Stage 3 Convalescent: Nonparoxysmal cough may persist 2-6wk after paroxysms subside, though paroxysms may recur months later.
4 AAO 2015. Seidman MD, et al. Clinical Practice Guideline: Allergic Rhinitis. Otolaryngol Head Neck Surg. 2015 Feb;152(1 Suppl):S1-43. PubMed® abstract | Free full-text Otolaryngol Head Neck Surg article PDF
Sx of allergic rhinitis incl sneezing, nasal congestion, rhinorrhea, itchy nose/throat/palate, postnasal drip, throat clearing, & cough; children may present w/ malaise & fatigue. Allergy tests (skin prick tests or allergen-specific serum IgE) helpful if dx uncertain or need to know specific allergen.
5 ACCP 2019. Chang AB, et al. Chronic Cough and Gastroesophageal Reflux in Children: CHEST Guideline and Expert Panel Report. American College of Chest Physicians. Chest. 2019 Jul;156(1):131-140. PubMed® abstract | Free full-text Chest article PDF @ PubMed® Central
GERD not common as pedi chronic cough etiology. Don’t empirically tx GERD w/o clinical features (recurrent regurgitation, infant dystonic neck posturing, heartburn/epigastric pain). In pts w/ consistent s/sx/tests for GERD: Don’t use acid suppression tx solely for chronic cough. If PPI/H2RA used as tx trials: Re-eval @4-8wk.
6 ACCP 2018. Chang AB, et al. Chronic Cough Related to Acute Viral Bronchiolitis in Children: CHEST Expert Panel Report. American College of Chest Physicians. Chest. 2018 Aug;154(2):378-382. PubMed® abstract | Free full-text article PDF @ PubMed® Central
7 AAP 2018. Choosing Wisely. American Academy of Pediatrics. Updated 6/12/18.
• Don’t prescribe/recommend cough/cold meds for resp illness in young children. Research shows little benefit despite serious side-effect potential. Multi-ingredient products pose OD risk if combined w/ other products.
8 FDA 2008. OTC Cough and Cold Products: Not For Infants and Children Under 2 Years of Age. Issued 1/17/08.
9 CDC 2017. Appropriate Antibiotic Use: Community. Pediatric Treatment Recommendations. Reviewed 2/01/17. Accessed 9/22/20
OTC cough/cold drugs: potential for harm, no proven benefit in children <6 yo.
10 FDA 2018. FDA Drug Safety Communication: FDA Requires Labeling Changes for Prescription Opioid Cough and Cold Medicines to Limit Their Use to Adults 18 Years and Older. Issued 1/11/18. Accessed 9/20/20
11 ACCP 2015. Vertigan AE, et al. Somatic Cough Syndrome (Previously Referred to as Psychogenic Cough) and Tic Cough (Previously Referred to as Habit Cough) in Adults and Children: CHEST Guideline and Expert Panel Report. Chest. American College of Chest Physicians. 2015 Jul;148(1):24-31. PubMed® abstract | Free full-text PDF @ PubMed® Central
12 DSM-5 2013. Very distressing, disruptive sx w/ excessive & disproportionate thoughts, feelings, behaviors regarding sx; persistent sx typically ≥6mo. Diagnostic and Statistical Manual of Mental Disorders (DSM-5). Somatic Symptom Disorder. American Psychiatric Association. 2013. PDF
Nonspecific dry cough (no specific-cough s/sx, no classic sound/type, no abnl exam/tests) Consider COVID-19. ✓CXR, ✓spirometry1,2 (3-6+ yo),1 in pts w/o specific-cough pointers1 from hx/exam/tests/cough type,1 triggers.2 ✓tobacco smoke/pollutants, child activity level, parental concerns.1 Nonspecific cough more likely to resolve w/o specific tx1
- Consider DDx.1 Nonspecific dry cough usually postviral cough or acute bronchitis. Test for pertussis if suspected3 (posttussive vomit, paroxysms, inspiratory whoop).1 Don’t routinely allergy test w/o s/sx allergies,2 though may be useful if dx uncertain or for allergy sx mgmt, per AAO.4 Rare: FB inhalation, asthma, mycosis, GERD,5 upper airway dz, ear problems, functional dz, drug effect, etc.1 Consider habit/tic/psychogenic cough1
- If eval negative: Watch, wait, re-eval in 2wk, per ACCP1 (up to 4wk, per ERS2), then follow to resolution1
- If cough persists @ 2-wk re-eval: Re-✓ for specific-cough s/sx.1 If none, then either watch/wait x2 more wks or consider inhaled steroid 2-4-wk tx trial1,2 (budesonide 400 ug/day or equivalent)1
- If tx trial chosen, f/u in 2-4wk. If sx resolving, consider asthma or asthma-like dz, f/u in 2-4 more wks; then stop steroids if no other asthma features.1 If sx persist on tx trial (after 4-8-wk steroid trial, per ERS2), stop inhaled steroids,2 re-eval for specific-cough s/sx1
- Don’t empirically tx UACS/postnasal drip from sinus dz (controversial pedi cause), GERD (rare pedi cause5), or asthma unless clinical features beyond cough present.1,5 Set time limit on tx trials.1 Post-acute viral bronchiolitis cough: Don’t use asthma drugs (unless wheeze/SOB/other asthma s/sx) or inhaled osmotic agents6
- Don’t use OTC cough meds, d/t adverse event risk, insufficient evidence of benefit. Honey may help cough (avoid if <1 yo).1 Don’t use codeine,1,2,7 gabapentin, or pregabalin in children.2 Insufficient evidence on PPIs or antileukotrienes in children, per ERS2
- For unexplained cough after comprehensive eval: Therapy for somatic cough disorder8,9 (aka, habit/tic/psychogenic) lacks evidence in children. Reassurance, psychotherapy, counseling, suggestion tx, hypnosis, etc, have been suggested2
Footnotes 1 ACCP 2020. Chang AB, et al. Managing Chronic Cough as a Symptom in Children and Management Algorithms: CHEST Guideline and Expert Panel Report. American College of Chest Physicians. Chest. 2020 Jul;158(1):303-329. PubMed® abstract | Free full-text Chest article PDF
Specific cough pointers:
• Cough sound/type: bark/brassy, honking, paroxysmal (+/- whoop), staccato, coughing up casts; habit/tic cough can be honking/barking, occur at nighttime.
• Hx: choking, chest pain, SOB/exertional dyspnea, face pain, purulent nasal d/c, hemoptysis, recurrent infxns, chronic lung/esophagus dz, feeding difficulty, growth/neurodevelopment issues
• Exam: ↑RR, wheeze, crepitation, abnl CV/chest wall exam, clubbing, cyanosis, face tender, purulent nasal d/c, hoarse/stridor
• Tests: abnl spirometry/O 2/CXR
Spirometry (pre-/post- beta-2 agonist)
• Doable for >6 yo (possible for >3 yo if pedi-trained staff present).
• If NL, doesn’t r/o asthma.
• Airway hyperresponsiveness may be temporary post-infxn or w/ allergic rhinitis; may not predict later asthma or asthma med response.
• FeNO: Role undefined in children w/o classic asthma sx.
DDx, eval for persistent cough
• Bronchiectasis/recurrent pneumonia (immunodeficiency, CF, FB, structural airway dz, congenital lesion, TEF/H-fistula, etc): sweat test, bronch, immune w/u, chest CT, Ba swallow, genetics
• Infxn (TB, non-TB mycobacteria, mycosis, parasites, etc): sputum/blood tests, bronch + lavage, CT chest
• Aspiration (abnl swallow/cough reflex, neuromuscular dz, larynx issue, tonsil/adenoid hypertrophy, severe GERD, TEF/H-fistula, etc): Ba swallow, bronch + lavage, video fluoro, pH meter, lung milk scan/salivagram
• Interstitial lung dz (drug/XRT effects, rheum dz): serum markers, HRCT, lung bx, genetics
• Abnl airway (tracheomalacia, extrinsic compression, etc): bronch + lavage, CT chest, MRI chest
• Cardiac dz (pulm HTN, cardiac edema): pedi cardiology referral, ECG, echo, cardiac cath
• Other pulm dz (sleep apnea, pulm edema, tumor, etc)
• Drug effect (eg, ACEI, immediately post-inhalation of asthma inhaler, new tic cough from dextroamphetamine, etanercept)
• Otogenic: ear-cough reflex. Vagal nerve activation by foreign matter/hair on eardrum
• Somatic cough syndrome (formerly habit/tic/psychogenic cough). Unexplained cough after comprehensive eval. Features: cough suppressibility, distractibility, suggestibility, variability, premonitory sense of single vs multiple tics
2 ERS 2020. Morice AH, et al. ERS Guidelines on the Diagnosis and Treatment of Chronic Cough in Adults and Children. Eur Respir J. 2020 Jan 2;55(1):1901136. PubMed® abstract | Free full-text article PDF @ PubMed® Central
• Triggers incl indoor/outdoor irritants: cold air, perfume, smoke, traffic emissions, bleach
• Somatic cough disorder (formerly habit/tic/psychosomatic): Dx only after extensive eval for other/uncommon causes. Cough features: suppressibility, distractibility, suggestibility, variability, premonitory sense about whether cough will be single or multiple.
3 CDC 2019. Pertussis (Whooping Cough). Centers for Disease Control and Prevention. Reviewed 10/25/19. Accessed 9/22/20
• Test: nasopharyngeal swab or aspirate for PCR, cx; special handling required.
• Stage 1 Catarrhal: Insidious sx onset w/in 5-10 days of exposure (max 21 days). Coryza, low-grade fever, initially intermittent mild cough gradually increases in severity.
• Stage 2 Paroxysmal: Cough persists x1-6wk. Multiple paroxysms of numerous rapid coughs (often at night) ending in whoop, thick mucus, posttussive emesis, long inspiratory effort, cyanosis, exhaustion. Whoop, emesis may be absent. Paroxysms disappear in 2-3wk.
• Stage 3 Convalescent: Nonparoxysmal cough may persist 2-6wk after paroxysms subside, though paroxysms may recur months later.
4 AAO 2015. Seidman MD, et al. Clinical Practice Guideline: Allergic Rhinitis. Otolaryngol Head Neck Surg. 2015 Feb;152(1 Suppl):S1-43. PubMed® abstract | Free full-text Otolaryngol Head Neck Surg article PDF
Sx of allergic rhinitis incl sneezing, nasal congestion, rhinorrhea, itchy nose/throat/palate, postnasal drip, throat clearing, & cough; children may present w/ malaise & fatigue. Allergy tests (skin prick tests or allergen-specific serum IgE) helpful if dx uncertain or need to know specific allergen.
5 ACCP 2019. Chang AB, et al. Chronic Cough and Gastroesophageal Reflux in Children: CHEST Guideline and Expert Panel Report. American College of Chest Physicians. Chest. 2019 Jul;156(1):131-140. PubMed® abstract | Free full-text Chest article PDF @ PubMed® Central
GERD not common as pedi chronic cough etiology. Don’t empirically tx GERD w/o clinical features (recurrent regurgitation, infant dystonic neck posturing, heartburn/epigastric pain). In pts w/ consistent s/sx/tests for GERD: Don’t use acid suppression tx solely for chronic cough. If PPI/H2RA used as tx trials: Re-eval @4-8wk.
6 ACCP 2018. Chang AB, et al. Chronic Cough Related to Acute Viral Bronchiolitis in Children: CHEST Expert Panel Report. American College of Chest Physicians. Chest. 2018 Aug;154(2):378-382. PubMed® abstract | Free full-text article PDF @ PubMed® Central
7 FDA 2018. FDA Drug Safety Communication: FDA Requires Labeling Changes for Prescription Opioid Cough and Cold Medicines to Limit Their Use to Adults 18 Years and Older. Issued 1/11/18. Accessed 9/20/20
8 DSM-5 2013. Very distressing, disruptive sx w/ excessive & disproportionate thoughts, feelings, behaviors regarding sx; persistent sx typically ≥6mo. Diagnostic and Statistical Manual of Mental Disorders (DSM-5). Somatic Symptom Disorder. American Psychiatric Association. 2013. PDF
9 ACCP 2015. Vertigan AE, et al. Somatic Cough Syndrome (Previously Referred to as Psychogenic Cough) and Tic Cough (Previously Referred to as Habit Cough) in Adults and Children: CHEST Guideline and Expert Panel Report. Chest. American College of Chest Physicians. 2015 Jul;148(1):24-31. PubMed® abstract | Free full-text PDF @ PubMed® Central
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