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## Complete Summary

#### GUIDELINE TITLE

Chronic cough in a child.

#### BIBLIOGRAPHIC SOURCE(S)

Finnish Medical Society Duodecim. Chronic cough in a child. In: EBM
Guidelines. Evidence-Based Medicine \[Internet\]. Helsinki, Finland:
Wiley Interscience. John Wiley & Sons; 2007 Mar 8 \[Various\].

#### GUIDELINE STATUS

This is the current release of the guideline.

This guideline updates a previous version: Finnish Medical Society
Duodecim. Prolonged cough in children. In: EBM Guidelines.
Evidence-Based Medicine \[Internet\]. Helsinki, Finland: Wiley
Interscience. John Wiley & Sons; 2004 Jun 15 \[various\]. \[7
references\]

### COMPLETE SUMMARY CONTENT

 SCOPE\
 METHODOLOGY - including Rating Scheme and Cost Analysis\
 RECOMMENDATIONS\
 EVIDENCE SUPPORTING THE RECOMMENDATIONS\
 BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS\
 IMPLEMENTATION OF THE GUIDELINE\
 INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT
CATEGORIES\
 IDENTIFYING INFORMATION AND AVAILABILITY\
 DISCLAIMER

### SCOPE

#### DISEASE/CONDITION(S)

Chronic cough

#### GUIDELINE CATEGORY

Diagnosis

#### CLINICAL SPECIALTY

Family Practice\
Pediatrics

#### INTENDED USERS

Health Care Providers\
Physicians

#### GUIDELINE OBJECTIVE(S)

Evidence-Based Medicine Guidelines collect, summarize, and update the
core clinical knowledge essential in general practice. The guidelines
also describe the scientific evidence underlying the given
recommendations.

#### TARGET POPULATION

Children with cough lasting longer than 6 to 8 weeks

#### INTERVENTIONS AND PRACTICES CONSIDERED

**Diagnosis**

1.  Searching for diagnostic clues for causes of prolonged cough

2.  Diagnostic investigations

    -   Blood counts, including eosinophils, C-reactive protein (CRP)
        and erythrocyte sedimentation rate (ESR)

    -   Investigations to establish microbial aetiology including the
        detection of antibodies to pertussis, mycoplasma and chlamydia

    -   X-ray studies

    -   Allergy investigations if indicated by history

    -   Peak expiratory flow readings in children over 5 years of age

    -   Spirometry

    -   Lung function tests

    -   pH measurement of the esophagus

    -   Bronchoscopy and esophagoscopy

    -   Measurement of immunoglobulin concentrations and alpha-1-trypsin
        or a sweat test

    -   Oscillometry and exercise testing

#### MAJOR OUTCOMES CONSIDERED

Not stated

### METHODOLOGY

#### METHODS USED TO COLLECT/SELECT EVIDENCE

Hand-searches of Published Literature (Primary Sources)\
Hand-searches of Published Literature (Secondary Sources)\
Searches of Electronic Databases

#### DESCRIPTION OF METHODS USED TO COLLECT/SELECT THE EVIDENCE

The evidence reviewed was collected from the Cochrane database of
systematic reviews and the Database of Abstracts of Reviews of
Effectiveness (DARE). In addition, the Cochrane Library and medical
journals were searched specifically for original publications.

#### NUMBER OF SOURCE DOCUMENTS

Not stated

#### METHODS USED TO ASSESS THE QUALITY AND STRENGTH OF THE EVIDENCE

Weighting According to a Rating Scheme (Scheme Given)

#### RATING SCHEME FOR THE STRENGTH OF THE EVIDENCE

**Classification of the Quality of Evidence**

+----+------------+----------------------------------------------------+
| ** | **Quality  | **Definition**                                     |
| Co | of         |                                                    |
| de | Evidence** |                                                    |
| ** |            |                                                    |
+====+============+====================================================+
| *  | **High**   | Further research is very unlikely to change our    |
| *A |            | confidence in the estimate of effect.              |
| ** |            |                                                    |
|    |            | -   Several high-quality studies with consistent   |
|    |            |     results                                        |
|    |            |                                                    |
|    |            | -   In special cases: one large, high-quality      |
|    |            |     multi-centre trial                             |
+----+------------+----------------------------------------------------+
| *  | **         | Further research is likely to have an important    |
| *B | Moderate** | impact on confidence in the estimate of effect and |
| ** |            | may change the estimate.                           |
|    |            |                                                    |
|    |            | -   One high-quality study                         |
|    |            |                                                    |
|    |            | -   Several studies with some limitations          |
+----+------------+----------------------------------------------------+
| *  | **Low**    | Further research is very likely to have an         |
| *C |            | important impact on confidence in the estimate of  |
| ** |            | effect and is likely to change the estimate.       |
|    |            |                                                    |
|    |            | -   One or more studies with severe limitations    |
+----+------------+----------------------------------------------------+
| *  | **Very     | Any estimate of effect is very uncertain.          |
| *D | Low**      |                                                    |
| ** |            | -   Expert opinion                                 |
|    |            |                                                    |
|    |            | -   No direct research evidence                    |
|    |            |                                                    |
|    |            | -   One or more studies with very severe           |
|    |            |     limitations                                    |
+----+------------+----------------------------------------------------+

GRADE (Grading of Recommendations Assessment, Development and
Evaluation) Working Group 2007 (modified by the EBM Guidelines Editorial
Team)

#### METHODS USED TO ANALYZE THE EVIDENCE

Systematic Review

#### DESCRIPTION OF THE METHODS USED TO ANALYZE THE EVIDENCE

Not stated

#### METHODS USED TO FORMULATE THE RECOMMENDATIONS

Not stated

#### RATING SCHEME FOR THE STRENGTH OF THE RECOMMENDATIONS

Not applicable

#### COST ANALYSIS

A formal cost analysis was not performed and published cost analyses
were not reviewed.

#### METHOD OF GUIDELINE VALIDATION

Peer Review

#### DESCRIPTION OF METHOD OF GUIDELINE VALIDATION

Not stated

### RECOMMENDATIONS

#### MAJOR RECOMMENDATIONS

**In General**

-   A chronic cough is defined as one that lasts for longer than 6 to 8
    weeks.

-   The most likely cause of a cough varies according to the age of the
    child.

-   Asthma is possible in children of all ages.

**Aetiology**

-   The most common causes **in an infant**

    -   Infection (the most common cause; otitis, bronchiolitis,
        bronchitis)

    -   Asthma, more rare

    -   Occasionally structural abnormalities of the respiratory tract
        (malacia, stenosis, tracheo-oesophageal fistula, vascular ring)

-   The most common causes **in a preschool child**

    -   Infection (otitis, sinusitis, bronchitis)

    -   Asthma

    -   A foreign body in the respiratory tract

-   The most common causes **in a school-age child**

    -   Asthma

    -   Infection (e.g. sinusitis)

    -   Psychogenic causes

-   A cough can be provoked by various irritants in the inspired air,
    such as cigarette smoke, or by cold weather.

-   Gastro-oesophageal reflux (GOR) is possible at any age.

-   A cough may also be psychogenic in origin or be provoked by a tic
    disorder.

-   Post-nasal drip associated with allergic rhinitis and mucosal
    irritation from the maxillary sinuses is a common cause of a chronic
    cough.

-   Very rare causes of a cough include cystic fibrosis, abnormal cilia,
    vagal stimulation of the respiratory tract and phrenic, pleuritic or
    pericardial irritation.

**Diagnostic Clues**

-   Bronchial hyperactivity may manifest itself as a nocturnal cough,
    especially in the small hours, or cough during exercise or in cold
    weather. If the child has asthma, close questioning will reveal
    difficulties in breathing (i.e. dyspnoea, even when the child\'s
    presenting symptom is a cough).

-   A cough originating from GOR is most noticeable at night time and
    may be associated with excessive burping or regurgitation.

-   A foreign body in the respiratory tract will usually cause a sudden
    burst of coughing, but the child may have a history of coughing for
    several weeks, even for months. It is only possible to confirm the
    diagnosis radiologically if the foreign body is radio-opaque. In
    other cases bronchoscopy is indicated.

    -   For an acute situation see the Finnish Medical Society Duodecim
        guideline \"Foreign Body in the Respiratory Passages.\"

-   A cough might continue for several weeks during the convalescent
    period of many respiratory tract infections, signifying bronchial
    irritation. Such infections include: rhinovirus, coronavirus,
    parainfluenza virus and respiratory syncytial (RS) virus infections
    as well as whooping cough and infections caused by *Mycoplasma
    pneumoniae* or *Chlamydia pneumoniae*.

**Diagnostic Investigations**

-   Blood counts, including eosinophils, C-reactive protein (CRP) and
    erythrocyte sedimentation rate (ESR).

-   Investigations to establish microbial aetiology include the
    detection of antibodies to pertussis, mycoplasma and chlamydia
    (acute and convalescent serums). If an acute infection is diagnosed,
    asthma investigations can be postponed.

-   X-ray studies after consideration.

-   Allergy investigations if indicated by history.

-   If there are grounds to suspect asthma (see the Finnish Medical
    Society Duodecim guideline \"Diagnosis and Treatment of Childhood
    Asthma\").

    -   Peak expiratory flow readings in children over 5 years of age
        (correct technique!)

    -   Spirometry may be carried out from late preschool age onwards.

-   In specialised care, after consideration:

    -   Lung function tests (see the Finnish Medical Society Duodecim
        guideline \"Diagnosis and Treatment of Childhood Asthma\").

    -   pH measurement in the oesophagus.

    -   Bronchoscopy and oesophagoscopy.

        -   If immotile-cilia syndrome is suspected, a biopsy of the
            cilia may be taken during the endoscopic examination for
            electron microscopic studies.

    -   Oesophageal pH determination.

    -   The measurement of immunoglobulin concentrations and
        alpha-1-trypsin or a sweat test.

    -   In preschool children, oscillometry may be used (with and
        without a bronchodilator) as well as exercise testing.

-   The diagnosis of asthma in a small child is usually based on
    clinical assessment, history of recurrent episodes of obstruction
    symptoms, and consideration of risk factors.

-   Attacks and medication trials, as functional tests are not
    available. It is very important that symptoms, the effect of
    medication and physical findings are recorded in the patient\'s
    medical notes.

**Related Resources**

Refer to the original guideline document for related evidence, including
Cochrane reviews and other evidence summaries.

#### CLINICAL ALGORITHM(S)

None provided

### EVIDENCE SUPPORTING THE RECOMMENDATIONS

#### TYPE OF EVIDENCE SUPPORTING THE RECOMMENDATIONS

Concise summaries of scientific evidence attached to the individual
guidelines are the unique feature of the Evidence-Based Medicine
Guidelines. The evidence summaries allow the clinician to judge how
well-founded the treatment recommendations are.

### BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS

#### POTENTIAL BENEFITS

Appropriate use of diagnostic investigations in children with chronic
cough

#### POTENTIAL HARMS

Not stated

### IMPLEMENTATION OF THE GUIDELINE

#### DESCRIPTION OF IMPLEMENTATION STRATEGY

An implementation strategy was not provided.

### INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT CATEGORIES

#### IOM CARE NEED

Getting Better\
Living with Illness

#### IOM DOMAIN

Effectiveness

### IDENTIFYING INFORMATION AND AVAILABILITY

#### BIBLIOGRAPHIC SOURCE(S)

Finnish Medical Society Duodecim. Chronic cough in a child. In: EBM
Guidelines. Evidence-Based Medicine \[Internet\]. Helsinki, Finland:
Wiley Interscience. John Wiley & Sons; 2007 Mar 8 \[Various\].

#### ADAPTATION

Not applicable: The guideline was not adapted from another source.

#### DATE RELEASED

2000 Apr 17 (revised 2007 Mar 8)

#### GUIDELINE DEVELOPER(S)

Finnish Medical Society Duodecim - Professional Association

#### SOURCE(S) OF FUNDING

Finnish Medical Society Duodecim

#### GUIDELINE COMMITTEE

Editorial Team of EBM Guidelines

#### COMPOSITION OF GROUP THAT AUTHORED THE GUIDELINE

*Primary Author*: Merja Kajosaari

#### FINANCIAL DISCLOSURES/CONFLICTS OF INTEREST

Not stated

#### GUIDELINE STATUS

This is the current release of the guideline.

This guideline updates a previous version: Finnish Medical Society
Duodecim. Prolonged cough in children. In: EBM Guidelines.
Evidence-Based Medicine \[Internet\]. Helsinki, Finland: Wiley
Interscience. John Wiley & Sons; 2004 Jun 15 \[various\]. \[7
references\]

#### GUIDELINE AVAILABILITY

This guideline is included in \"EBM Guidelines. Evidence-Based
Medicine\" available from Duodecim Medical Publications, Ltd, PO Box
713, 00101 Helsinki, Finland; e-mail: <info@ebm-guidelines.com>; Web
site: [www.ebm-guidelines.com](http://www.ebm-guidelines.com/).

#### AVAILABILITY OF COMPANION DOCUMENTS

None available

#### PATIENT RESOURCES

None available

#### NGC STATUS

This summary was completed by ECRI on August 28, 2001. The information
was verified by the guideline developer as of October 26, 2001. This
summary was updated by ECRI on December 9, 2002. This summary was
verified by the developer on April 2, 2003. The summary was updated most
recently on October 1, 2004. This NGC summary was updated by ECRI
Institute on December 2, 2008.

#### COPYRIGHT STATEMENT

This NGC summary is based on the original guideline, which is subject to
the guideline developer\'s copyright restrictions.

### DISCLAIMER

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© 1998-2008 National Guideline Clearinghouse

Date Modified: 12/15/2008