Definitions for the level of evidence, strength of recommendation, and net benefit follow the "Major Recommendations."
- Children with chronic cough require careful and systematic evaluation for the presence of specific diagnostic indicators. Level of evidence, expert opinion; benefit, substantial; grade of recommendation, E/A
- Children with chronic cough should undergo, as a minimum, a chest radiograph and spirometry (if age appropriate). Level of evidence, expert opinion; benefit, intermediate; grade of recommendation, E/B
- In children with specific cough, further investigations may be warranted, except when asthma is the etiologic factor. Level of evidence, expert opinion; benefit, intermediate; grade of recommendation, E/B
- Children with chronic productive purulent cough should always be investigated to document the presence or absence of bronchiectasis and to identify underlying and treatable causes such as cystic fibrosis and immune deficiency. Level of evidence, low; benefit, substantial; grade of recommendation, B
- In children with chronic cough, the etiology should be defined and treatment should be etiologically based. Level of evidence, expert opinion; benefit, substantial; grade of recommendation, E/A
- In children with nonspecific cough, cough may spontaneously resolve, but children should be reevaluated for the emergence of specific etiologic pointers (see Table below entitled "Pointers to the Presence of Specific Cough"). Level of evidence, low; benefit, substantial; grade of recommendation, B
Table: Pointers to the Presence of Specific Cough
Abnormality |
Examples of Etiology |
Auscultatory findings |
Wheeze-intrathoracic airway lesions (eg, tracheomalacia, asthma); crepitations, any airway lesions (from secretions), or parenchyma disease such as interstitial disease |
Cardiac abnormalities |
Associated airway abnormalities, cardiac failure |
Chest pain |
Arrhythmia, asthma |
Dyspnea or tachypnea |
Any pulmonary airway or parenchymal disease |
Chest wall deformity |
Any pulmonary airway or parenchymal disease |
Digital clubbing |
Suppurative lung disease |
Daily moist or productive cough |
Suppurative lung disease |
Exertional dyspnea |
Any airway or parenchymal disease |
Failure to thrive |
Any serious systemic including pulmonary illness such as cystic fibrosis |
Feeding difficulties |
Any serious systemic including pulmonary illness, aspiration |
Hemoptysis |
Suppurative lung disease, vascular abnormalities |
Hypoxia/cyanosis |
Any airway or parenchyma disease, cardiac disease |
Immune deficiency |
Suppurative lung disease or atypical infection |
Neurodevelopmental abnormality |
Aspiration lung disease |
Recurrent pneumonia |
Immunodeficiency, atypical infections, suppurative lung disease, congenital lung abnormalities, trachea-esophageal H fistulas |
- In children with nonspecific cough and risk factors for asthma, a short trial (ie, 2 to 4 weeks) of beclomethasone, 400 micrograms/day, or the equivalent dosage with budesonide may be warranted. However, most children with nonspecific cough do not have asthma. In any case, these children should always be reevaluated in 2 to 4 weeks. Level of evidence, fair; benefit, intermediate; grade of recommendation, B
- In children who have started therapy with a medication, if the cough does not resolve during the medication trial within the expected response time, the medication should be withdrawn and other diagnoses considered. Level of evidence, low; benefit, intermediate; grade of recommendation, C
- In children with cough, cough suppressants and other over the counter (OTC) cough medicines should not be used as patients, especially young children, may experience significant morbidity and mortality. Level of evidence, good; benefit, none; grade of recommendation, D
- In children with nonspecific cough, parental expectations should be determined, and the specific concerns of the parents should be sought and addressed. Level of evidence, low; benefit, intermediate; grade of recommendation, E/B
- In all children with cough, exacerbating factors such as exposure to tobacco smoke (ETS) exposure should be determined and interventional options for the cessation of exposure advised or initiated. Level of evidence, low; benefit, substantial; grade of recommendation, B
- Children should be managed according to the studies and guidelines for children (when available), because etiologic factors and treatments in children are sometimes different from those in adults. Level of evidence, low; benefit, substantial; grade of recommendation, B
- In children <14 years of age with chronic cough, when pediatric-specific cough recommendations are unavailable, adult recommendations should be used with caution. Level of evidence, expert opinion; benefit, intermediate; grade of recommendation, E/B
Definitions:
Quality of the Evidence
Good = evidence is based on good randomized controlled trials (RCTs) or meta-analyses
Fair = evidence is based on other controlled trials or RCTs with minor flaws
Low = evidence is based on nonrandomized, case-control, or other observational studies
Expert opinion = evidence is based on the consensus of the carefully selected panel of experts in the topic field. There are no studies that meet the criteria for inclusion in the literature review.
Strength of Recommendations
A = strong recommendation
B = moderate recommendation
C = weak recommendation
D = negative recommendation
I = no recommendation possible (inconclusive)
E/A = strong recommendation based on expert opinion only
E/B = moderate recommendation based on expert opinion only
E/C = weak recommendation based on expert opinion only
E/D = negative recommendation based on expert opinion only
Net Benefit
Substantial = There is evidence of benefit that clearly exceeds the minimum clinically significant benefit and evidence of little harm
Intermediate = Clear evidence of benefit but with some evidence of harms, with a net benefit between that defined for "substantial" and "small/weak"
Small/weak = There is evidence of a benefit that may not clearly exceed the minimum clinically significant benefit, or there is evidence of harms that substantially reduce (but do not eliminate) the benefit such that it may not clearly exceed the minimum clinically significant benefit
None = Evidence shows that either there is no benefit or the benefits equal the harms
Conflicting = Evidence is inconsistent with regard to benefits and/or harms such that the net benefit is uncertain
Negative = Expected harms exceed the expected benefits to the population
Table: Relationship of Strength of the Recommendations Scale to Quality of Evidence and Net Benefits
|
Net Benefit |
Quality of Evidence |
Substantial |
Intermediate |
Small/Weak |
None |
Conflicting |
Negative |
Good |
A |
A |
B |
D |
I |
D |
Fair |
A |
B |
C |
D |
I |
D |
Low |
B |
B |
C |
I |
I |
D |
Expert Opinion |
E/A |
E/B |
E/C |
I |
I |
E/D |