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Complete Summary

GUIDELINE TITLE

Prolonged cough in children.

BIBLIOGRAPHIC SOURCE(S)

  • 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 STATUS

Note: This guideline has been updated. The National Guideline Clearinghouse (NGC) is working to update this summary.

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)

Prolonged cough

GUIDELINE CATEGORY

Diagnosis
Management

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 prolonged cough

INTERVENTIONS AND PRACTICES CONSIDERED

  1. History of symptoms and conditions in family or day-care
  2. Examination of tympanic membrane with a pneumatic otoscope or by acoustic impedance testing (for suspected otitis media)
  3. Ultrasonography of sinuses and sinus radiography (for suspected sinusitis)
  4. Measurement of peak expiratory flow (PEF) values, including before and after exercise and after inhalation of sympathomimetic (for suspected asthma)
  5. Medication trials with sympathomimetics or inhaled corticosteroids (for suspected asthma)
  6. Patient education for the proper administration of the inhaled medicine
  7. A bronchodilatation test or a free exercise test and auscultation of expiration (for suspected asthma)
  8. Symptom diary (for suspected asthma)
  9. Chest x-ray (for suspected foreign body)
  10. Bronchoscopy (for suspected foreign body)
  11. Specialist care examination by pH registration and, if necessary, endoscopy (for suspected gastro-oesophageal reflux).
  12. Nedocromil sodium for prevention of exercise-induced bronchoconstriction

Note: Inhaled anticholinergic medications were considered but not recommended.

MAJOR OUTCOMES CONSIDERED

  • Predictive value of diagnostic instruments
  • Effects of nedocromil sodium on the severity and duration of exercise-induced bronchoconstriction (as measured by the maximum percentage fall in forced expiratory volume in one minute, maximum percentage fall in peak expiratory flow, time to recover lung function after exercise-induced bronchoconstriction)
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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

Levels of Evidence

  1. Strong research-based evidence. Multiple relevant, high-quality scientific studies with homogeneous results.
  2. Moderate research-based evidence. At least one relevant, high-quality study or multiple adequate studies.
  3. Limited research-based evidence. At least one adequate scientific study.
  4. No research-based evidence. Expert panel evaluation of other information.

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

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RECOMMENDATIONS

MAJOR RECOMMENDATIONS

Note: This guideline has been updated. The National Guideline Clearinghouse (NGC) is working to update this summary. The recommendations that follow are based on the previous version of the guideline.

The levels of evidence [A-D] supporting the recommendations are defined at the end of the "Major Recommendations" field.

Basic Rule

  • A child with continuous cough without an obvious cause should be referred to a paediatrician, so that investigations for allergy, pulmonary function tests, and possibly investigations for gastro-oesophageal reflux, bronchoscopy, and histological examination of airway mucosa can be performed.

Causes of Prolonged Cough

Recurrent Infections

  • The cough is not caused by a single episode of disease but rather by frequently occurring new infections associated (e.g., with the beginning of day-care).
  • A careful history of the symptoms and the conditions in the family and in day-care is often helpful.

An Infectious Focus

  • Cough may be the only significant symptom of silent otitis media with effusion in small children or subacute sinusitis in older children.
  • In sinusitis cough is often present during the night or in the morning. It is not merely the result of mucous "running down" to the throat, but both the middle ear and the sinuses have cough receptors that cause the cough (McCracken, 1986). Ultrasonography of the maxillary sinuses is a safe method also for repeated examinations of maxillary sinus fluid retention.
  • The tympanic membranes should be examined with a pneumatic otoscope or by acoustic impedance testing. Mere visual inspection is not sufficient.
  • Indications for chest radiography are considered carefully; repeated radiographic examinations during the same cough episode are usually unnecessary.

Whooping Cough, Mycoplasma, Chlamydia

  • See the Finnish Medical Society guideline on whooping cough for the clinical manifestations.
  • Cough associated with pulmonary mycoplasma and chlamydia infections may be prolonged and continue for weeks, in the manner of whooping cough.

Hyperreactivity After an Infection

  • Bronchial hyperreactivity lasting for weeks is common after viral or mycoplasma infections. The most important symptoms are bouts of cough during exercise and in cold weather (McCracken, 1986; Henry et al., 1983).

Asthma

A Foreign Body in the Respiratory Tract

  • The patient may have had symptoms for weeks or months, without a foreign body being suspected.
  • When taking the history of a coughing patient it is always worthwhile to ask specifically for the possibility of a foreign body.
  • If the foreign body is radio-opaque (which is rare) the diagnosis can be made by chest radiograph. In other cases a bronchoscopy is indicated (Puhakka et al., 1989).

Other Causes of Cough

  • Children subjected to cigarette smoke at home may suffer from continuous cough.
  • Gastro-oesophageal reflux may associate with prolonged cough. The history may reveal a considerable tendency for rumination in infancy (Puhakka et al., 1989). The child should be examined in specialist care by using pH registration and, if necessary, endoscopy.
  • Typical manifestations of psychogenic cough include hawking, speaking with a loud voice and coughing in specific situations. In 10% of children with prolonged cough the condition is psychogenic.

Related Evidence

  • Nedocromil sodium prevents exercise-induced bronchoconstriction (Spooner, Saunders, & Rowe, 2002) [A].
  • There is currently no evidence to support the use of inhaled anticholinergic medications in the management of prolonged nonspecific cough in children (Chang, McKean, & Morris, 2004) [D].

Definitions:

Levels of Evidence

  1. Strong research-based evidence. Multiple relevant, high-quality scientific studies with homogeneous results.
  2. Moderate research-based evidence. At least one relevant, high-quality study or multiple adequate studies.
  3. Limited research-based evidence. At least one adequate scientific study.
  4. No research-based evidence. Expert panel evaluation of other information.

CLINICAL ALGORITHM(S)

None provided

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EVIDENCE SUPPORTING THE RECOMMENDATIONS

REFERENCES SUPPORTING THE RECOMMENDATIONS

References open in a new window

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. The type of supporting evidence is identified and graded for select recommendations (see the "Major Recommendations" field).

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BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS

POTENTIAL BENEFITS

Appropriate diagnostic investigations into the cause of prolonged cough in children

POTENTIAL HARMS

Not stated

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IMPLEMENTATION OF THE GUIDELINE

DESCRIPTION OF IMPLEMENTATION STRATEGY

An implementation strategy was not provided.

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INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT CATEGORIES

IOM CARE NEED

Getting Better

IOM DOMAIN

Effectiveness

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IDENTIFYING INFORMATION AND AVAILABILITY

BIBLIOGRAPHIC SOURCE(S)

  • 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]

ADAPTATION

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

DATE RELEASED

2000 Apr 17 (revised 2004 Jun 15)

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: Editors

FINANCIAL DISCLOSURES/CONFLICTS OF INTEREST

Not stated

GUIDELINE STATUS

Note: This guideline has been updated. The National Guideline Clearinghouse (NGC) is working to update this summary.

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.

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.

COPYRIGHT STATEMENT

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

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DISCLAIMER

NGC DISCLAIMER

The National Guideline Clearinghouse™ (NGC) does not develop, produce, approve, or endorse the guidelines represented on this site.

All guidelines summarized by NGC and hosted on our site are produced under the auspices of medical specialty societies, relevant professional associations, public or private organizations, other government agencies, health care organizations or plans, and similar entities.

Guidelines represented on the NGC Web site are submitted by guideline developers, and are screened solely to determine that they meet the NGC Inclusion Criteria which may be found at http://www.guideline.gov/about/inclusion.aspx .

NGC, AHRQ, and its contractor ECRI Institute make no warranties concerning the content or clinical efficacy or effectiveness of the clinical practice guidelines and related materials represented on this site. Moreover, the views and opinions of developers or authors of guidelines represented on this site do not necessarily state or reflect those of NGC, AHRQ, or its contractor ECRI Institute, and inclusion or hosting of guidelines in NGC may not be used for advertising or commercial endorsement purposes.

Readers with questions regarding guideline content are directed to contact the guideline developer.
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