Chronic cough in children — short-answer question

Part A — Definition, classification and pointers (10 marks)

a) Define chronic cough in children and state the diagnostic branch point (3 marks)

Chronic cough in a child is a daily cough persisting for more than four weeks — deliberately shorter than the eight-week adult threshold, because a child still coughing at a month usually has an identifiable, treatable cause rather than a viral tail. The first and most powerful classifying step is to decide whether the cough is wet or dry. [1]

b) Explain the classification by cough quality and by specific pointers (4 marks)

A wet or productive cough implies excessive airway secretions and suppurative disease, whereas a dry cough points to airway irritation or a sensitised reflex. The second axis is specific versus non-specific: a specific cough carries a pointer to underlying disease, while a non-specific cough is a dry cough in a well, thriving child with a normal examination and chest X-ray. This grid directs whether the child is investigated or observed. [1] [2]

c) List the specific-cough pointers you would seek (3 marks)

Wet or productive cough, cough from birth or the neonatal period, a choking episode suggesting foreign body, failure to thrive, digital clubbing, chest-wall deformity, exertional dyspnoea, haemoptysis, recurrent pneumonia, cardiac signs, and neurodevelopmental disease with aspiration risk. A single positive pointer converts observation into investigation. [1]

Part B — Management (10 marks)

a) Give your working diagnosis and initial management for this wet cough (6 marks)

In a thriving preschool child with an isolated chronic wet cough, no other pointers, and normal baseline tests, the leading diagnosis is protracted bacterial bronchitis. I would treat with a trial of an appropriate oral antibiotic for at least two weeks; amoxicillin-clavulanate has the strongest randomised evidence. Resolution of the cough within this period both treats the child and confirms the diagnosis. I would stop the ineffective salbutamol and counsel against over-the-counter cough medicines, which are ineffective and potentially harmful. [2] [3]

b) Describe your plan if the cough persists after antibiotics (4 marks)

If the cough only partially responds or recurs, I would extend the antibiotic course to four weeks. If it still fails to clear after an adequate course, this is no longer simple protracted bacterial bronchitis and I would escalate: flexible bronchoscopy with bronchoalveolar lavage for microbiology and to exclude a retained foreign body or airway malformation, a chest CT to look for bronchiectasis, and a work-up for cystic fibrosis and immunodeficiency. Persistent wet cough despite treatment has an underlying cause until proven otherwise. [2]