PURPOSE OF THE STUDY.
Use of cough algorithms or pathways can potentially lead to earlier diagnosis and reduce morbidity, unnecessary costs, and medication use associated with chronic cough. The 2006 CHEST guidelines on chronic cough in children advocated use of a cough pathway based on limited data, and research in chronic cough has progressed in the past decade. This study looked at 10 years of systematic reviews to present the summary of evidence behind these CHEST recommendations.
The age cutoff for the CHEST cough guidelines is ≤14 years. Chronic cough is defined as the presence of daily cough for at least 4 weeks in duration.
Data were collected from systemic reviews, existing guidelines, and primary studies published in English until August 2015. The study then examined various aspects in the approach to chronic cough management in children based on key questions (KQs) by using the Population, Intervention, Comparison, Outcome format. CHEST methodical guidelines and Grading of Recommendations Assessment, Development, and Evaluation framework were used to support the evidence-based graded recommendations. A consensus-based Delphi method was employed for the final grading.
There is high-quality evidence that the use of a systemic approach to pediatric-specific cough management improves clinical outcomes and that management should be based on cough characteristics and associated clinical history. Although there was evidence from several pathways, the highest evidence was from the use of the CHEST approach.
CHEST pediatric chronic cough guidelines have been around for over a decade but were initially based on limited evidence. There are now more studies showing high-quality evidence for standardizing the management of cough >4 weeks in children ≤14 years of age to improve our diagnosis of these children, manage them more appropriately, and improve quality of life. In evaluating chronic cough in children, providers should base management on cough characteristics and clinical history, avoid or limit the time frame for empirical trials, and obtain a chest radiograph and spirometry (pre- and post-β2 agonist) when appropriate. There are insufficient data to recommend the testing for airway hyperresponsiveness in all children with chronic cough and moderate-quality data to support AHR when spirometry is normal and asthma is suspected or symptoms are present.
The evidence base supporting the 2006 CHEST Cough Guidelines approach has grown in the past decade. Protocolized approaches to managing pediatric chronic cough significantly improve clinical outcomes. In summary, it is important for providers to obtain a thorough history in children with chronic cough and then obtain a chest radiograph for all children and spirometry only for children ages ≥6 years. Other tests should not be routinely performed unless otherwise clinically indicated. In the meantime, we await more trials for data on some of the new recommendations that are consensus as opposed to evidence-based, particularly in primary care.
- Copyright © 2017 by the American Academy of Pediatrics