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Jump to Key Points SAN DIEGO — Pediatricians should check their assumptions when a child comes down with a chronic cough, a pulmonologist cautioned colleagues at the American Academy of Pediatrics (AAP) 2026 National Conference.
Kids never get bronchitis? Not true. Asthma likely explains isolated chronic cough? No. Cough suppression and over-the-counter cold drugs can be helpful? Maybe not.
What should pediatricians do? Rely on established guidance. “A systematic approach using pediatric cough algorithms improves clinical outcomes in children with chronic cough,” said Ajay Kasi, MD, of Children’s Healthcare of Atlanta and Emory University in Atlanta, Georgia, in a presentation.
Kasi offered these tips about diagnosing and treating chronic cough, which is defined as a cough lasting at least 4 weeks in children aged 14 years or younger:
- Chronic cough in children = ≥4 weeks; use pediatric cough algorithms.
- Cough quality helps dx: barky/brassy, paroxysmal, staccato, wet/productive.
- Routine CXR + spirometry recommended; bronchodilator response suggests reversible obstruction.
- Daily wet cough ≥4 weeks without other cause → suspect PBB; antibiotics indicated.
- Isolated dry cough rarely asthma/reflux; stop asthma meds if no response in 2–4 weeks.
Consider the Type of Cough
“If a child presents with a barky or a brassy-sounding cough, it could indicate croup, habit cough, or tracheomalacia,” Kasi said. “If a child presents with paroxysmal or spasmodic cough with or without an inspiratory whoop, think about pertussis and parapertussis. If an infant presents with staccato cough, a repetitive cough with short inhalation between each cough, then think about chlamydia in infants.”
If a child expectorates airway casts, think of a rare disease called plastic bronchitis.
Also keep in mind that “there is good evidence that over-the-counter cough and cold medicines may not be helpful in the treatment of acute cough and chronic cough, and there’s a potential to cause harm,” he said. Cough suppression can also spell trouble, he added.
Routinely Order X-Rays and Spirometry
Kasi noted that CHEST guidelines recommend x-rays and spirometry in children with chronic cough. “If there are abnormalities, they would indicate disease.”
Spirometry does require good effort and cooperation, he said, although it can be feasible in kids as young as 6 years and even as young as 3 years.
If there are signs of obstructive lung disease, he said, spirometry with a bronchodilator could help identify a reversible airway obstruction.
Wet Cough? Consider Bronchitis. Yes, Bronchitis
Pediatricians have traditionally been taught that kids don’t get bronchitis, Kasi said. In fact, they can develop protracted bacterial bronchitis (PBB). “It’s usually an isolated, chronic, wet, or productive cough,” Kasi said. “Often, children are misdiagnosed as having asthma.”
Per the guidelines, “if they present with a daily wet or productive cough for at least 4 weeks and they have no signs or symptoms of other causes of cough, you would suspect PBB and go ahead and treat them with antibiotics.”
Isolated Dry Chronic Cough? Follow the Algorithm
“Studies have shown that asthma is typically not a cause for isolated chronic cough in children,” Kasi said. Children with asthma often present with wheezing, recurrent episodes of shortness of breath, and exertional dyspnea, he said. “And they may have response to bronchodilators or abnormalities on the pulmonary function test with bronchodilator responsiveness, either on spirometry or clinically.”
However, asthma symptoms may be more elusive in preschool-age children, who may not be able to perform spirometry or explain what they’re feeling. “That’s why the guidelines recommend a potential trial of [asthma] therapy. If there is no improvement in the cough with 2-4 weeks of inhaled steroids and inhaled bronchodilators, then it’s very unlikely to be asthma, so the guidelines recommend stopping the medicines” — not increasing them.
Other Possible Cough Causes
“Reflux is a common cause of chronic cough in adults,” Kasi said. “However, it is not commonly identified as a cause of chronic cough in children. Acid suppression medicine should not be empirically used for chronic cough in children.”
Habit cough, a kind of tic, is typically “absent during sleep, and when the child is engaged, like playing their favorite video game,” he said. The so-called suggestion therapy — visit habitcough.com for details — and a mental health referral may be appropriate.
Most Patients Can Be Helped
In an interview, John Oppenheimer, MD, allergist and immunologist and co-author of the CHEST guidelines in Morristown, New Jersey, concurred with Kasi’s recommendations. “Don’t empirically treat, use the patient’s history, physical exam, and lab findings to provide precision in their care and if you are still stumped, don’t hesitate to refer,” he said.
“Cough can significantly impact the quality of life of the patient and their family. But with a thoughtful approach, the vast majority can achieve control.”
Kasi reported having no disclosures. Oppenheimer disclosed having relationships with GSK; Aquestive Therapeutics; AstraZeneca/Amgen; Chiesi Farmaceutici S.p.A.; DBV Technologies; ARS Pharmaceuticals; Teva Pharmaceuticals; Novartis; Sanofi; AbbVie; Annals of Allergy, Asthma & Immunology; Medscape; and UpToDate.
