See also

Pertussis/Whooping cough
Asthma
Foreign body
Croup

Key points

1. The most common cause of cough is an upper respiratory tract infection (usually viral in nature)
2. Investigations and treatment are rarely required for well children with a short history of cough
3. Children who have a persistent daily cough lasting >4 weeks should be assessed and investigated with a CXR and spirometry (if able), with consideration given to further investigations and management

Background

• Cough is a common symptom and for most children is self-limiting
• Young children develop 6-12 respiratory tract infections per year, usually accompanied by cough. In most children, the cough is self-limiting, most resolve without treatment in 1-3 weeks
• For healthy children with a short history of cough (<4 weeks) and no red flags, further investigation and management is not required
• Key definitions
  • Acute cough: lasting up to 2 weeks
  • Protracted acute cough: daily cough lasting 2-4 weeks
  • Chronic cough: daily cough lasting >4 weeks
  • Specific cough: cough occurring with condition known to be cause of chronic cough
  • Non-specific cough: chronic cough without a defined cause (in children this will usually undergo spontaneous resolution)
• Chronic cough warrants further assessment

The most common cause of cough in children is a viral upper respiratory tract infection or post-infectious cough. The likelihood of other causes depends on clinical findings, cough duration and whether the cough is wet or dry.

The table below outlines common causes of cough.

Assessment

Initial assessment

• determine duration of cough and whether wet or dry
• elicit red flag symptoms or findings that may indicate serious underlying disease
• identify causes of specific cough or recent respiratory infections

History

Examination

• Fever, coryza or other signs of acute infection
• Increased work of breathing, hypoxia, stridor, chest signs (wheeze, crackles, crepitations)
• Faltering growth (or growth failure)
• Signs of cardiac failure (oedema, hepatomegaly, heart murmur)
• Signs of chronic suppurative lung disease/bronchiectasis (clubbing, poor growth, chest wall deformity)
• ENT examination for signs of rhinosinusitis

Red flags in chronic cough

• Shortness of breath (at rest or exertional)
• Recurrent episodes of chronic or wet or productive cough
• Recurrent pneumonia
• Chest pain
• Haemoptysis
• Systemic symptoms (fever, weight loss, growth failure)
• Neurodevelopmental abnormality
• Feeding difficulties (including choking/vomiting)
• Stridor and other respiratory noises
• Abnormal clinical respiratory examination (eg crackles, digital clubbing)
• Abnormal systemic examination (eg growth failure)
• Abnormal chest x-ray
• Abnormal lung function
• Co-existing chronic disease (eg immunodeficiency, syndromes)

Management

Investigations and treatment are rarely needed in otherwise well children who have a short history (<4 weeks) of non-specific cough

• Over the counter cough medicines and decongestants are not recommended due to lack of proven efficacy and potential safety risks
• Empiric use of antibiotics, steroids, proton pump inhibitors and antihistamines are not recommended
• Honey is often proposed as a treatment for cough, but there is no strong evidence supporting its effectiveness, and it carries risks such as infant botulism (in infants <12 months), dental caries and aspiration

All children presenting with cough should have

• education around avoidance of airway irritants eg cigarette smoking, vaping, e-cigarettes and wood-fire heaters
• understanding of when to seek repeat assessment (transition to chronic cough)
• acknowledgement of parental concerns and reassurance

Further assessment (including investigations and/or treatment) is required for:

• acutely unwell children (see sepsis, community acquired pneumonia, asthma, foreign body, pertussis, croup, bronchiolitis)
• children with a persistent (chronic) cough for >4 weeks
• specific cause of cough suspected on assessment

Consider consultation with local paediatric team when

Chronic cough requiring further assessment and management

Findings suggestive of an underlying condition associated with chronic cough

Consider referral to paediatric respiratory physician when

• Chronic wet cough and failure to respond to 4 weeks of appropriate antibiotics
• Recurrent episodes of chronic wet cough (>3 episodes of PBB/year)
• Chronic dry cough persisting >6 months and failure to respond to appropriate treatment (eg empiric trial of asthma treatment)
• Assessment is suggestive of specific cough, or red flags are present

Consider transfer when

Children requiring care above the level of comfort of the local hospital

For emergency advice and paediatric or neonatal ICU transfers, see Retrieval Services

Consider discharge when

• Child is stable
• Investigations and follow up arranged if needed

Additional resources

Sound of wet cough (audio file)

History Taking as a Diagnostic Tool in Children With Chronic Cough (Frontiers in Pediatrics publication)

Chronic cough resources (Lung Foundation Australia)

Diagnosis and assessment of chronic cough in children - clinical algorithm (Lung Foundation Australia)

Parent information

Cough (RCH Patient Handout)

Protracted Bacterial Bronchitis (PBB) in Children (American Thoracic Society)

Chronic cough in children (Lung Foundation Australia)

Interactive lung health education tool for Indigenous children/families (Menzies)

Last updated March 2025