Management of chronic cough in children

Advice on managing chronic cough in children, understanding symptoms, possible causes and suitable investigations.

Chronic cough is a common presenting symptom in children, accounting for a high number of repeat consultations. Chronic cough is defined as a non-resolving daily cough lasting longer than 4-8 weeks. There is no consensus on the duration in children.

Most cases of cough relate to the respiratory infections that would be expected an otherwise healthy child. But chronic cough can have a significant impact on a family’s quality of life — it affects the child’s sleep, school attendance and play. Cough may also be the first sign of a serious illness.

Careful evaluation of the chronic cough, to identify any features that merit referral and address parental concerns, is crucial.

Symptom reporting

Accurate and reliable symptom reporting is important in the assessment of cough. Parental reporting of cough does not correlate well with the frequency, duration or intensity of the actual objective cough.

In many cases the reported 'severity' of coughing in a child is related to how it affects the parents or teachers. Parental discrimination between a wet and a dry cough, however, is a good predictor of secretions in the lower airway.

In cases of isolated chronic cough a history and examination, followed by targeted investigations if necessary, should place the child in one of five broad diagnostic categories:

  • The normal, well child
  • The child with serious underlying illness such as cystic fibrosis or TB
  • The child with non-serious, treatable illness such as gastro-oesophageal reflux disease (GORD) or upper airway cough syndrome
  • The child with an asthma syndrome
  • The child with psychogenic cough

Parental reporting of the child’s cough does not correlate well with the frequency, duration or intensity of the actual cough

Clinical evaluation

Clinical evaluation of cough should always include a detailed history including environmental factors, particularly exposure to tobacco smoke, and eliciting parental concerns and expectations. Examination must include a respiratory, cardiovascular and ENT assessment. See table below.

History and examination of a child with chronic cough
History Examination
  • Age of onset
  • Duration
  • Severity
  • Time course
  • Alleviating and triggering factors
  • Quality of cough, for example barking, wheezing or honking
  • Exposure to smoking
  • Diurnal variability
  • Associated cold symptoms
  • Relation with meals
  • Wet or dry, sputum and haemoptysis
  • Wheeze
  • Dyspnoea
  • Fever
  • Failure to gain weight
  • Upper airway symptoms (rhinitis, ear infections, glue ear)
  • History of choking
  • Contact with TB or HIV
  • Possible allergies
  • Immunisation status
  • Response to prior therapy
  • Choking or coughing on swallowing
  • Whether cough disappears when sleeping
  • Conduct ear, nose and throat examination
  • Check for nasal polyps (cystic fibrosis must be excluded)
  • Check for chest deformities
  • Auscultate chest
  • Conduct cardiac examination
  • Look for evidence of atopy
  • Identify failure to thrive
  • Check for digital clubbing
  • Ask the child to perform their usual cough, and huff (forced expiration) while palpating the chest

Causes of cough

In some children the quality of cough is recognisable and suggestive of specific aetiology. A barking or brassy cough suggests tracheomalacia. A paroxysomal cough with or without whoop suggests pertussis and parapertussis infection. A chronic wet cough, especially in the morning, suggests suppurative lung disease such as bronchiectasis. The box below outlines serious conditions that may present with cough.

Serious causes
  • Cystic fibrosis
  • Chronic suppurative lung disease/bronchiectasis
  • Immune deficiencies
  • Primary ciliary disorders
  • Recurrent pulmonary aspiration
  • Retained inhaled foreign body
  • TB
  • Anatomical disorder (bronchomalacia lung malformation, vascular rings)
  • Interstitial lung disease
  • Cardiac disease

In older children, cough may be associated with psychological problems because cough can be cortically modulated. Psychogenic cough should always be considered a differential in the older child. Typically, the cough disappears completely during sleep and may have an unusual honking character.

Isolated chronic cough is a poor marker of asthma. Asthma should not be considered on the basis of cough alone without other typical features. Cough-predominant or cough-variant asthma does exist, but is a rare diagnosis. Bronchial hyper-responsiveness or reversible airways obstruction are both key features of asthma, which can help to identify children with cough-predominant asthma.

Psychogenic cough typically disappears during sleep and may have an unusual honking character Investigations

Possible relevant investigations range from simple tests such as oxygen saturations and chest X-ray (CXR), to invasive tests such as chest high-resolution CT scan, bronchoscopy, barium swallow and sleep study.

The key decision is whether to refer to secondary care. A CXR is a good baseline and easily accessible investigation for all children with chronic cough. An abnormality on CXR is strongly suggestive of underlying pathology and should direct onward referral.

Before starting treatment there should always by a systematic effort to exclude serious underlying illness and establish a specific diagnosis. OTC cough medicines are not useful, and cough suppressants may be actively dangerous.


Management of an otherwise well child with a persistent, dry non-productive cough includes reassurance and monitoring. Most of these coughs are post-viral and will resolve spontaneously. Pay attention to exacerbating factors, particularly exposure to tobacco smoke.

Parental smoking cessation is a successful therapy to reduce childhood cough. Behavioural counselling for mothers who smoke reduces young children's reported and objectively measured exposure to tobacco smoke.

Empirical treatment of possible GORD-related cough with proton-pump inhibitors (PPIs) is not recommended. PPIs do not improve cough and are associated with an increase in respiratory infections.

Offer reassurance and monitoring to an otherwise well child with a persistent, dry non-productive cough

In children with a chronic dry cough and a history of atopic sensitisation a trial of inhaled corticosteroid (ICS) can be considered, for example beclometasone 200 micrograms twice daily for 6-8 weeks. Remember that a high proportion of these children would improve irrespective of treatment. Upon improvement, the ICS should be stopped and a diagnosis of asthma syndrome should only be made if the cough reoccurs.

Children with a chronic wet cough who are otherwise well with no concerning features may have protracted bacterial bronchitis, a chronic infection of the conducting airways with high incidence in the preschool age group.

A prolonged (two to three week) course of a broad-spectrum antibiotic such as co-amoxiclav is appropriate first-line management. This should be followed by review and onward referral if the cough persists.

  • Dr Atul Gupta is a consultant in paediatric respiratory medicine, King’s College Hospital, London, UK

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Further Reading

  1. Gupta A, McKean M, Chang A. Management of chronic non-specific cough in childhood: an evidence-based review. Arch Dis Child Educ Pract Ed 2007;92(2):33-9.
  2. Shields M, Bush A, Everard M et al. BTS guidelines: Recommendations for the assessment and management of cough in children. Thorax 2008;63(Suppl 3):iii1-iii15.

Recommended content: Management of acute cough in children (0.5 credits)

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