Chronic Cough - Paediatric CPC

For clinical advice, please telephone the relevant metropolitan Local Health Network switchboard and ask to speak to the relevant specialty service.

Southern Adelaide Local Health Network

• Flinders Medical Centre (08) 8204 5511

Women's and Children's Health Network

• Women’s and Children’s Hospital (08) 8161 7000

Inclusions

• bronchiectasis (non-cystic fibrosis)
• protracted bacterial bronchitis (PBB), defined as a pattern of daily wet cough for longer than 4 weeks duration which typically may occur after an initial viral illness, not responding to prolonged 2-week course of oral broad-spectrum antibiotics
• aspiration syndromes e.g. chronic/feed related aspiration
• non-resolution of a non-specific cough

Triage categories

Category 1 (appointment clinically indicated within 30 days)

• chronic cough with any of the following concerning features
  • systemic symptoms such as fever, weight loss, faltering growth
  • feeding difficulties (including choking or vomiting)
  • stridor and other respiratory noises
  • abnormal clinical respiratory examination including clubbing
  • abnormal chest x-ray (CXR)
  • history of haemoptysis

Category 2 (appointment clinically indicated within 90 days)

• episode of protracted bacterial bronchitis (PBB) not responding to empirical treatment with 2 weeks of broad-spectrum antibiotics
• recurrent pneumonia (≥ 2 per year)
• dry cough present for > 8 weeks (if wet cough, > 4 weeks if no response to up to 2 weeks of empiric antibiotics) with normal CXR and spirometry (if accessible) and no improvement following treatment trial (see Clinical Management Advice)
• bronchiectasis (non-cystic fibrosis)
• aspiration syndromes e.g. chronic/feed related aspiration

Category 3 (appointment clinically indicated within 365 days)

• nil

Essential referral information

Completion required before first appointment to ensure patients are ready for care. Please indicate in the referral if the patient is unable to access mandatory tests or investigations as they incur a cost or are unavailable locally.

• symptoms including duration, severity, associated syncope, incontinence, shortness of breath, paroxysm-related symptoms such as vomiting or colour change
  
• presence or absence of concerning features
  • persistent fevers
  • night sweats
  • weight loss, include estimated amount
  • haemoptysis
  • significant contacts with tuberculosis or pertussis
• detailed medical history including history of asthma, atopy, rhinitis, ear, nose and throat problems, gastro-oesophageal reflux disorder
• previous treatment and response
• results of chest x-ray (CXR), spirometry, sputum sample in children with wet cough able to produce a sample, and/or any blood tests
• neonatal history including prematurity
• weight and height/length
• developmental assessment
• coughing or gagging with oral intake
• family history of cystic fibrosis
• any environmental factors which may increase susceptibility to infection e.g. housing, environmental smoke, tobacco smoke exposure
• any medication storage/administration needs, particularly if prolonged courses of antibiotics are expected to be required

Additional information to assist triage categorisation

• relevant allied health/diagnostic/imaging reports, including location of company and accession number
• consider pulmonary function tests if patient is > 6 years old pre and post bronchodilator, if able to access
• consider CXR if clinically indicated e.g. suspicion of inhaled foreign body
• symptoms including
  • any diurnal variation in severity e.g. nocturnal or positional
  • triggers e.g. air temperature, food, talking, exercise
  • swallowing difficulties
  • voice change

Clinical management advice

• if suspected protracted bacterial bronchitis (PBB) (chronic wet cough with no signs or symptoms suggesting an alternative diagnosis):
  • treat with a 2 to 4-week course of oral antibiotics until resolution of wet cough
  • suggest empirical treatment with broad spectrum antibiotic such as amoxicillin/clavulanic acid 25mg/kg (max 875mg amoxicillin component) twice a day
  • if penicillin-allergic, consider azithromycin or co-trimoxazole
• if suspected asthma, offer trial of salbutamol to assess for a clinical response
• if non-specific dry cough with normal chest x-ray +/- spirometry and no signs or symptoms suggesting a diagnosis, it may be appropriate to adopt a watchful waiting approach
• evaluate exposure to tobacco smoke and other pollutants, as well as reviewing parental expectations and concerns
• consider blood tests for respiratory serology (pertussis and mycoplasma) for chronic dry cough
• consider screening for immunodeficiency (baseline immunoglobulins) for chronic wet cough
• note that tuberculosis (TB) may present as a chronic wet cough. If a patient from a high-risk population (e.g. Indigenous, migrant from TB endemic country) has a chronic wet cough, consider referral to Infectious Diseases or the Royal Adelaide Hospital TB clinic.

Clinical resources

• Chronic suppurative lung disease and bronchiectasis in children and adults in Australia and New Zealand: A position statement from the Thoracic Society of Australia and New Zealand and The Australian Lung Foundation
• Management of bronchiectasis and CSPD in indigenous children and adults in remote and rural Australian communities
• Cough in Children and Adults: Diagnosis, Assessment and Management (CICADA). Summary of an updated position statement on chronic cough in Australia
• The Royal Children’s Hospital Melbourne – Clinical Practice Guidelines: Cough
• Thoracic Society of Australia & New Zealand (TSANZ) – Clinical Documents: Paediatric
• Position statement of the Thoracic Society of Australia and New Zealand. Cough in children: definitions and clinical evaluation

Consumer resources

• Menzies School of Health Research – Chronic Suppurative Lung Disease/Bronchiectasis (Chronic Lung Sickness)
• SA Health – Tuberculosis (TB) cases in Aboriginal communities
• The Royal Children’s Hospital Melbourne – Kids Health Information Fact Sheet: Bronchiolitis 
• The Royal Children’s Hospital Melbourne – Kids Health Information Fact Sheet: Cough

Reason for request

• to establish a diagnosis
• for treatment or intervention
• for advice and management
• for specialist to take over management
• for a specified test/investigation the General Practitioner cannot order
• for other reason (e.g. rapidly accelerating disease progression)
• transfer of care from another tertiary service
• clinical judgement indicates a referral for specialist review is necessary.

Patient demographic details

• full name, including aliases
• date of birth
• residential and postal address
• telephone contact number/s – home, mobile and alternative
• Medicare number, where eligible
• name of the parent or caregiver, if appropriate
• preferred language and interpreter requirements
• identifies as Aboriginal and/or Torres Strait Islander

Clinical modifiers

• impact on employment
• impact on education
• impact on home
• impact on activities of daily living
• impact on ability to care for others
• impact on personal frailty or safety
• identifies as Aboriginal and/or Torres Strait Islander

Other relevant information

• Willingness to have surgery, where surgery is a likely intervention.
• Choice to be treated as a public or private patient.
• Compensable status, e.g. DVA, Work Cover, Motor Vehicle Insurance, etc.
• Relevant social history, including identifying if you feel your patient is from a vulnerable population, under guardianship/out-of-home care arrangements and/or requires a third party to receive correspondence on their behalf.
• Triage of a specialist outpatient referral is based on clinical decision making to allocate an appropriate urgency categorisation.
  
• Where appropriate and where available, the referral may be streamed to an associated public allied health and/or nursing service. Access to some specific services may include initial assessment and management by associated public allied health and/or nursing, which may either facilitate or negate the need to see the public medical specialist.
• A change in patient circumstance (such as condition deteriorating or pregnancy) may affect the urgency categorisation and should be communicated as soon as possible.
• All new referrals will be triaged by a consultant and appointment times scheduled according to clinical urgency.

Adolescents transitioning from paediatric to adult specialist services require a formal handover from paediatric specialist clinician to adult specialist clinician as well as a formal referral from the referring specialist to ensure initial transfer of care is completed.

The General Practitioners role in this process is to provide support to patients as part of holistic care. All ongoing referrals to specialists can subsequently be provided by the General Practitioner once the transfer of care has occurred.