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Management algorithm

Management Algorithm


Cough is a common symptom in children that is usually short-lived. A daily cough of 3 weeks or longer is unusual and is defined as chronic. Daily cough for greater than 4-6 weeks may mean there is an underlying lung disease. A comprehensive clinical history and examination together with appropriate investigations and follow up are recommended. 

Assessment of chronic cough is based on identifying a cause for the chronic cough. The history and examination should identify the type of cough, presence of red flags, any signs of a specific diagnosis, and signs of chronic or systemic disease. The presence of stridor indicates an upper airway disorder which may require ENT referral. Consider an inhaled foreign body and refer urgently to ENT if this is suspected.

The type of cough may be a pointer to a specific cause eg honking or brassy cough in malacia or habit cough, cough associated with wheeze in asthma, wet cough in Protracted Bacterial Bronchitis (PBB) or bronchiectasis. A dry cough often indicates a non-specific cause and can usually be managed with a period of watchful waiting; however, a chronic dry cough may also be seen in asthma, reflux and aspiration.

A dry chronic cough without recurrent pneumonia or bronchiolitis is less likely to require investigation. A wet or productive cough or a chronic cough associated with recurrent pneumonia or bronchiolitis is likely to require further investigation.

Red flags include:

  • Neonatal onset of cough
  • Coughing or choking during feeding
  • Stridor
  • Sudden onset of cough or a history of choking (possible foreign body)
  • Systemic signs or symptoms (shortness of breath, hypoxia or cyanosis, night sweats, weight loss, haemoptysis)
  • Signs of chronic disease (clubbing, poor growth, chest wall deformity)

Social determinants of health

Respiratory health is improved when living in housing that is insulated, dry, has heating and is not overcrowded. Minimise exposure to tobacco smoke and be aware of infectious contacts eg preschool.  Consider what support may be available for whanau/family to improve health.


Prescribe antibiotics 2 weeks at a time for patients with suspected PBB, directed against local sensitivities for Strep pneumoniae, Haem influenzae and Moraxella. Examples of suitable antibiotic choices include amoxycillin, amoxycillin/clavulanate, co-trimoxazole.

CT scan and CXRs should be performed when "well" if possible; ie at least 6-8 weeks after an acute exacerbation and after a prolonged period of antibiotic +/- age appropriate chest physiotherapy treatment.

Children with bronchiectasis on chest CT scan should be managed as per guidelines. Children without bronchiectasis on CT may be labelled as PBB and recurrences treated with 2 weeks of antibiotics. Children with PBB and frequent recurrences ≥3/yr should be investigated and treated the same as those with bronchiectasis and according to bronchiectasis guidelines.

Initial screen: FBC & differential, Immunoglobulins, Total IgE.
Common Variable Immune Deficiency may fully develop after 6 years of age - consider repeat testing if initial screening was performed at a young age.

Further immune testing: If raised clinical concern due to severe symptoms, frequent recurrences ≥ 3/yr or any chronic sequelae such as bronchiectasis then add conjugate vaccine responses (diptheria, tetanus, haemophilus influenzae B).

Extended immune testing: If above screening abnormal, severe disease or increased likelihood of immune deficiency then consult with an immunologist regards HIV* serology, pre & post Pneumovax23 responses*, DHR/NBT* test and lymphocyte subsets testing
(*tertiary services may consider performing some of these tests without needing to consult)

Pneumovax23 responses require careful co-ordination.

  1. Before giving Pneumovax take blood, write on lab form "Pre-pneumovax pneumococcal antibodies. Hold serum to send away for serotype specific levels if indicated"
  2. Give Pneumovax or ask GP to give on the same day as or a few days after 1.
  3. 4-6 weeks after Pneumovax given (emphasise to family that it must be done during this period), have second blood test. On that form, write "Post-pneumovax pneumococcal antibodies. Send with pre- sample for serotype specific levels if indicated."

Note: responses to the standard conjugate pneumococcal vaccine are different from those to the polysaccharide Pneumovax23 vaccine and do not add further information beyond routine vaccine response testing.

More extended testing such as proliferation studies should only be performed by or under the direction of an immunologist.


Children with chronic cough should be routinely screened for symptoms of antegrade aspiration (coughing or choking on drinking; worsened wheeze or cough after drinking) and symptoms of reflux related aspiration. In infants with recurrent exacerbations or persistent xray change aspiration should be considered and investigated even in the absence of symptoms.

Primary Ciliary Dyskinesia

Children with chronic cough should be routinely screened for symptoms of primary ciliary dyskinesia (PCD). Those with at least 2 of the 4 key clinical features for PCD should undergo diagnostic testing (see Primary Ciliary Dyskinesia guideline)

  • Unexplained neonatal respiratory distress in term infant
  • Year-round daily cough beginning before 6 months of age
  • Year-round daily nasal congestion beginning before 6 months of age
  • Organ laterality defect

Information for Families

Kidshealth website, including video 'Cough Free, the Way to Be'


  1. Management of Children With Chronic Wet Cough and Protracted Bacterial Bronchitis Chest Guideline and Expert Panel Report. Chang et al. CHEST 2017; 151(4):884-89
  2. Kantar A, Chang AB, Shields MD,et al. ERS statement on protracted bacterial bronchitis in children. Eur Respir J2017; 50: 1602139 []
  3. British Thoracic Society guideline for non-CF bronchiectasis. Pasteur et al . Thorax 2010. Volume 65 Issue Suppl I
  4. Chronic Suppurative Lung Disease And Bronchiectasis In Children And Adults In Australia And New Zealand. Chang et al. Med J Aust 2015; 202 (1): 21-23. || doi: 10.5694/mja14.00287

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Document Control

  • Date last published: 15 April 2019
  • Document type: Clinical Guideline
  • Services responsible: Paediatric Respiratory
  • Author(s): Elizabeth Edwards, David McNamara
  • Owner: David McNamara
  • Editor: Greg Williams
  • Review frequency: 2 years

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