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Primary care management and referral guideline Primary care management and referral guideline

Chronic Cough in Children – Management and referral guideline

Red flags

  • Suspected inhaled foreign body
  • Infant with episodes of apnoea or cyanosis

Purpose

Primary care management and referral guidelines contain condition-based information for GPs about when to refer a patient, assessment and management measures that should be taken prior to submitting a referral, and what should be included in a referral to the relevant outpatient department or specialist service.

Introduction

  • Cough is common in children, usually presents acutely in the setting of an obvious respiratory tract infection, and is generally self‑limited, resolving in 1 to 3 weeks.
  • Chronic cough (daily cough for > 4 weeks1) in children should prompt further assessment to establish the underlying cause.

Assessment

Take an age appropriate history. Ask about:

  • cough features.

    Cough features
    Ask about:

    • onset – sudden onset of cough while eating or playing, or without a viral prodrome, may suggest foreign body inhalation.
    • duration – in children, a cough lasting > 4 weeks is considered chronic.
    • type of cough e.g., dry or wet, productive or non‑productive:
      • Honking cough may suggest psychogenic cough.
      • Wet cough generally indicates a specific underlying problem e.g., viral infection, protracted bronchitis, foreign body.
    • pattern of cough:
      • Paroxysmal cough with post-tussive vomiting may suggest pertussis – see Pertussis (Whooping Cough).
      • Staccato cough suggests chlamydia in infants.
      • Cough which is absent during sleep suggests habit cough.
  • related factors.

    Related factors

    • Cough triggers e.g., drinking, lying down, exercise, allergens
    • Symptoms of chronic rhinitis, atopic conditions, and asthma
    • Other symptoms e.g., swallowing trouble, haemoptysis, sweats, poor growth
    • Exercise tolerance
    • Medication history
    • Perinatal factors e.g., prematurity, low birth weight, respiratory distress syndrome
    • Tobacco smoke exposure and home environment e.g., carpets, mould from air conditioning units, proximity to farms or industry
    • Relevant family history e.g., asthma
    • Risk of tuberculosis exposure e.g., socioeconomic factors, country of origin

Try to differentiate between cough from serial respiratory tract infections and true persistent cough.

Respiratory tract infections

  • Studies with cough meters show that normal children cough 10 to 11 times per day and rarely at night. During a respiratory infection, this can increase to 60 to 100 times a day.
  • Preschoolers can have up to 12 respiratory tract infections per year. Cough can be expected to last 1 to 3 weeks with each episode.
  • What parents report as a chronic cough over winter often turns out to be repeated episodes with separate infections (i.e., the child is still coughing from one infection when they get the next).

Perform a thorough age appropriate examination:

  • Check general appearance, alertness, hydration status, and vital signs.
  • Look for fever, tachycardia, tachypnoea, and reduced oxygen saturation, and determine if the patient is unwell.
    Tachypnoea – World Health Organization (WHO) guidelines

    Age Respiratory rate indicating tachypnoea
    < 2 months 60 per minute
    2 to 12 months > 50 per minute
    1 to 5 years > 40 per minute
    > 5 years > 30 per minute
    Measure when not crying or coughing.

    Source: World Health Organization – Standard Case Management of Pneumonia in Children in Developing Countries: The Cornerstone of the Acute Respiratory Infection Programme

  • Record height and weight, and plot in an appropriate growth chart – available in most general practice software.
  • Look for features suggestive of underlying pathology.
    Features suggestive of underlying pathology

    • Added respiratory sounds, stridor, wheeze, crackles, crepitation
    • Reduced respiratory sounds
    • Increased respiratory effort
    • Chest wall abnormality in obstructive airway disease
    • Abnormal heart sounds or pulses, or murmurs suggesting underlying heart disease
    • Dextrocardia in Kartagener’s syndrome which may be associated with primary ciliary dyskinesia
    • Finger clubbing or cyanosis
    • Hepato- or splenomegaly in cystic fibrosis related liver disease, chronic infection, malignancy
    • Lymphadenopathy of chronic infection or malignancy

Consider differential diagnosis (list not exhaustive):

  • Post-infectious cough (most common)
    Post-infectious cough

    • Consider if prolonged dry cough continuing after an otherwise resolved respiratory tract infection.
    • The child is otherwise well and there are no other specific features indicating an alternative cause.
  • Pertussis (whooping cough) (common)
    Pertussis (whooping cough)

    • Suspect if bouts of paroxysmal cough typically followed by vomiting, choking, or taking a big gasping breath which causes a ‘whooping’ sound.
    • Older children, adolescents, and adults may just have a persistent paroxysmal cough without other specific features.
    • See Pertussis (Whooping Cough).
  • Protracted bacterial bronchitis
    Protracted bacterial bronchitis

    • Suspect if wet, moist, and productive cough lasting for > 4 weeks in an otherwise well child, without specific pointers of an alternative cause.
    • Response to prolonged antibiotic treatment (2 to 4 weeks) confirms the diagnosis.
  • Rhinitis and rhinosinusitis
    Rhinitis and rhinosinusitis

    • Consider in patients with persistent or chronic nasal symptoms (e.g., nasal discharge or obstruction), especially if associated atopy.
    • Rhinitis may occur with or without bacterial sinusitis.
    • See Rhinitis and Nasal Obstruction in Children .
  • Asthma
    Asthma

    • Suspect in patients with a paroxysmal, predominantly dry cough, associated with wheeze and specific triggers (allergens, exercise, cold air).
    • Personal or family history of atopy and family history of asthma increase the probability.
    • Diagnosis is supported by reversible airflow limitation on spirometry or symptom improvement with bronchodilators.

    See Non-acute Asthma in Children.

  • Aspiration
    Aspiration

    • Foreign body aspiration:
      • Coughing after choking while eating or playing should be considered to be foreign body aspiration until proved otherwise.
      • Delayed presentation of a foreign body may include recurrent or persistent pneumonia, or unexplained persistent croupy cough or wheeze with fever and dyspnoea. In a large number of these cases there is no history of choking episode.
    • Chronic or recurrent aspiration (uncommon):
      • Children who recurrently aspirate food or stomach contents usually have pre-existing global developmental delay or neuromuscular disease affecting swallowing, craniofacial malformations, or oesophageal problems (e.g., GORD, tracheo‑oesophageal fistula, oesophageal surgery, achalasia).
      • Clues to aspiration syndrome are choking, rattly coughing, and wheezing, regularly associated with feeding or drinking, vomiting, lying down, or sleeping.
  • Less common causes of chronic cough
    Less common causes of chronic cough

    • Bronchiectasis
      Bronchiectasis

      • Can follow a severe chest infection, or be associated with underlying disease e.g., cystic fibrosis (CF), ciliary defects, recurrent aspiration, immunodeficiency.
      • Suspect if multiple episodes of antibiotic‑responsive wet cough or persistent wet cough not responding to antibiotic therapy.
      • Chest hyperexpansion and clubbing may be present.
      • Chest X-ray may show peribronchiolar changes or obviously dilated bronchi. Spirometry may show an obstructive pattern.
    • Congenital heart disease
    • Cough-receptor hypersensitivity – a diagnosis of exclusion, in a healthy child with a persistent dry cough, on minor stimulation
    • Cystic fibrosis (CF)
      Cystic fibrosis (CF)
      Patients with CF may have been missed on newborn screening and present later in infancy or early childhood with recurrent respiratory infections, intestinal malabsorption, and poor growth.
    • GORD
    • Malignancy
    • Obstructive sleep apnoea, possibly with enlarged tonsils
    • Other infections e.g., atypicals (mycoplasma, chlamydia, legionella)
    • Persistent atelectasis or consolidation
    • Primary ciliary dyskinesia
    • Psychogenic cough
      Psychogenic cough

      • Consider in patients with:
        • a tic-like throat clearing or soft cough before speaking.
        • an exceptionally loud and honking, dry cough, repeated mechanically, particularly in certain situations (e.g., when parents are present).
      • Characteristically absent during sleep.
      • Often seen in school‑aged children.
    • Tracheomalacia or bronchomalacia – usually associated with stridor and a very brassy cough
    • Tuberculosis (TB)
      Tuberculosis (TB)

      • Suspect if known exposure to adults with TB, or time spent living in a refugee camp or a high‑prevalence country.
      • Most children with TB will develop latent TB, manifested by a Mantoux conversion only. If clinical disease develops, it often presents with non-specific symptoms (fever and lethargy). Children aged < 5 years are at higher risk of disseminated TB and TB meningitis.
      • Children aged < 2 years with symptomatic chest tuberculosis are more likely to have intrathoracic lymph node disease which may cause compression and present as wheeze. Pulmonary disease is less common and tends to be paucibacillary, therefore less infectious.
      • Adolescents are more likely to present with adult‑type pulmonary tuberculosis i.e., chronic productive cough with infiltrates or cavitations. They have multibacillary disease and are more infectious.

Consider investigations on a case-by case basis:

  • Arrange a chest X-ray (inspiratory and expiratory) if:
    • suspected pneumonia.
    • suspected foreign body.
    • features suggesting chronic respiratory condition e.g., poor growth, chest deformity, finger clubbing.
    • haemoptysis.
  • Consider spirometry in all children aged > 6 years with chronic cough.
    Spirometry

    • Reversible airflow limitation (i.e., > 12% bronchodilator response in FEV1) supports the diagnosis of asthma.
    • A normal spirometry does not rule out asthma.
  • Consider sputum culture in older children with productive or moist cough recurring or persisting despite adequate antibiotic therapy.
    Sputum culture

    • Usual respiratory organisms include Haemophilus influenzae, Streptococcus pneumoniae, and Moraxella catarrhalis.
    • Unusual organisms that indicate an underlying condition (e.g., bronchiectasis) include Staphyloccocus aureus and gram negative bacteria e.g., Pseudomonas aeruginosa.

Management

If suspected inhaled body, infant with episodes of apnoea or cyanosis, or patient seriously ill, discuss with your local paediatric team on call or arrange transfer to your nearest ED as appropriate.

If other serious underlying pathology suspected, discuss immediately with your local paediatric team and manage accordingly.

Serious underlying pathology

  • Bronchiectasis
  • Cystic fibrosis (CF)
  • Immunodeficiency suggested by repeated invasive respiratory infections
  • Primary ciliary dyskinesia
  • Malignancy
  • Tuberculosis (TB)
  • Underlying respiratory structural anomaly

If post-viral cough is suspected, provide education and reassurance.

Education and reassurance

  • Reassure parents about the benign and self-limiting nature of the condition.
  • Advise against tobacco smoke exposure.
  • Advise that over‑the‑counter cough mixtures are not recommended in children due to lack of proven efficacy, and potential safety risk in younger children.
  • Discuss alternatives to current day‑care arrangements in very young children.

If protracted bacterial bronchitis (PBB):

  • treat with antibiotics.
    Antibiotics for protracted bacterial bronchitis

    • If no sputum culture is available to guide treatment, prescribe 2 to 4 weeks (depending on symptom response) of:
      • amoxicillin/clavulanate 22.5 mg/kg (maximum 875 mg) per dose twice a day, or
      • if penicillin hypersensitivity, trimethoprim + sulphamethoxazole (co-trimoxazole) 4 mg/kg + 20 mg/kg (maximum 160 mg + 800 mg) twice a day.
    • If sputum culture available, treat according to sensitivity.
  • refer to your local General Paediatrics service if recurrent or non-resolving PBB.

If respiratory tract infection due to atypical bacteria (e.g., mycoplasma, chlamydia) suspected, consider:

  • a watch and wait approach.
    Watch and wait approach

    • Consider if patient is otherwise well.
    • Advise patient and parents about the self-limited nature of the infection and limited benefit from antibiotics in most cases.
    • Offer regular follow‑up and advise the patient or parent to seek immediate medical advice if any concerns.
  • arranging serology to confirm diagnosis.
  • prescribing antibiotic therapy for atypical bacteria (based on symptoms and preference of the patient or parent).
    Antibiotic therapy for atypical bacteria

    • Prescribe a macrolide antibiotic:
      • Azithromycin 10 mg/kg (up to 500 mg) per dose orally once a day for 3 to 6 days, or
      • Clarithromycin 7.5 mg/kg (up to 500 mg) per dose orally 12‑hourly for 7 days
    • Advise cough will last some weeks.

If another specific cause for persistent cough is found, manage as indicated. Follow the relevant guideline for:

If no specific cause is found and child is otherwise well:

  • reassure and offer regular follow up until cough resolves.
  • advise parent to seek medical advice if any warning signs or symptoms develop (e.g., fever, tachypnoea, increased sputum).

If any other concerns, discuss with your local paediatric team.

When to refer

  • If suspected inhaled body, infant with episodes of apnoea or cyanosis, or patient seriously ill, discuss with your local paediatric team on call or arrange transfer to your nearest ED as appropriate.
  • If recurrent or non-resolving PBB, refer to your local General Paediatrics service.
  • If serious underlying pathology suspected, or any other concerns, discuss with your local paediatric team.

Referring to your local Paediatric services

Public

Check the patient’s catchment area before requesting assessment. When services are available in the patient’s local area, refer the patient to the local hospital.

Queensland Children’s Hospital

1. Referral can be made by either:

  • GP Smart Referral via BP or Medical Director
  • Secure messaging
    Secure messaging
    Send a written request to the Referral Centre via eReferral
    (Medical Objects ID: RQ402900084, HealthLink ID: qldrchld):

    • To download templates, see Referral Forms.
    • If unable to attach investigations or use secure messaging, fax to 1300 407 281.

    For more information, contact the Referral Centre:
    P.O. Box 3474, South Brisbane QLD 4101
    Phone 1300 762 831
    Fax 1300 407 281

2. Check the minimum referral criteria and insert the required information into referral.

Private

Search for a provider via the National Health Services Directory.

Guideline approval and disclaimer

Guideline approval history
Version no. 1.0 Approval date 03/09/2018 Review date 01/09/2021

Disclaimer

Referral guidelines contain condition-based information for GPs about when to refer a patient, assessment and management measures that should be taken prior to submitting a referral, and what should be included in a referral to the relevant outpatient department or specialist service.
Our referral guidelines aim to help GPs decide which tests and treatments are appropriate for their patients based on their presenting symptoms and previous medical history. Consulting the relevant referral guideline before a patient is referred on to a specialist service may mean that an appointment can be booked sooner and the outcome of their consultation is more conclusive. It can also eliminate the need to refer a patient where preliminary tests rule out the need for specialist intervention.
The information contained within our referral guidelines has been developed in collaboration with specialist medical professionals. They are intended to support referring GPs and are in no way intended to replace their professional medical judgement.

Resources

For health professionals

For families

  • NPS MedicineWise – Coughs
  • The Royal Children’s Hospital Melbourne – Cough
  • The Sydney Children’s Hospitals Network – Mantoux Skin Test

Contact details

Hospital Switchboard
(Ask for the General Paediatric Registrar)
t: 07 3068 1111

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