Chronic cough in children — structured oral (viva)

Branch 1 — Definition and first move

Examiner: "This child has coughed for six weeks. What is your definition of chronic cough, and what is the first thing you want to establish?" Candidate: Chronic cough in a child is a daily cough persisting for more than four weeks, shorter than the adult eight-week threshold because a child coughing at a month usually has a treatable cause. My first move is to establish whether the cough is wet or dry — here it is wet, which immediately points me toward suppurative airway disease rather than a benign non-specific cough. [1]

Branch 2 — Differential and pointers

Examiner: "It is a wet cough. What is your leading diagnosis, and what pointers are you looking for?" Candidate: In a thriving preschool child with an isolated chronic wet cough, the leading diagnosis is protracted bacterial bronchitis. I actively search for specific-cough pointers that would suggest something more serious: cough from birth, a choking episode, failure to thrive, clubbing, chest-wall deformity, haemoptysis, exertional dyspnoea, or recurrent pneumonia. This child has none, which supports protracted bacterial bronchitis and lets me proceed with a treatment trial. [1] [3]

Examiner: "Why does it matter that this cough never fully clears?" Candidate: Failure to return to a cough-free baseline distinguishes true pathology from recurrent viral illness, and it is the hallmark of protracted bacterial bronchitis. An untreated persistent wet cough sits on a continuum toward chronic suppurative lung disease and bronchiectasis, so it must be explained and treated, not dismissed. [3] [2]

Branch 3 — Management

Examiner: "How will you treat him?" Candidate: I would treat presumptively for protracted bacterial bronchitis with a two-week course of an appropriate oral antibiotic; amoxicillin-clavulanate has the strongest randomised evidence. Resolution within this period both treats and confirms. I would also address the modifiable risk factor by counselling firmly on removing household tobacco smoke, and I would avoid over-the-counter cough medicines, which are ineffective and potentially harmful. [2]

Examiner: "The cough improves but returns a month later, and again after that. What now?" Candidate: Recurrent episodes — more than three a year — should prompt investigation rather than repeated empirical courses. I would extend treatment and escalate to flexible bronchoscopy with bronchoalveolar lavage, a chest CT to look for bronchiectasis, and a work-up for immunodeficiency and cystic fibrosis. Recurrent protracted bacterial bronchitis can be the harbinger of underlying suppurative lung disease. [2] [3]

Branch 4 — Avoiding adult reflexes

Examiner: "A colleague suggests a trial of inhaled steroids, antihistamines, and a proton pump inhibitor. Your view?" Candidate: I would not. The adult triad of asthma, gastro-oesophageal reflux, and upper-airway cough syndrome rarely explains an isolated chronic cough in a young child, and empirical multi-drug trials are evidence-poor, delay the correct diagnosis, and expose the child to unnecessary medication. I would make one rational intervention — the antibiotic trial for the wet cough — and reassess objectively. [1] [2]