Children with chronic cough without gastrointestinal symptoms of gastroesophageal reflux (GER) and no underlying lung disease should not be treated empirically for gastroesophageal reflux disease (GERD) according to a report published in Chest.

A team of researchers performed systematic reviews using the Population, Intervention, Comparison, Outcome framework to answer the following key questions (KQs) specific to the association between GERD and chronic cough (>4 w duration) in children who do not have underlying chronic lung disease:

KQ 1: Should empirical treatment for GERD be used in children with chronic cough who do not have gastrointestinal GER symptoms?

KQ 2: Does treatment for GERD resolve cough in children with chronic cough who have gastrointestinal GER symptoms?

KQ 3: In children with or without GER symptoms who have chronic cough, what GER-based therapies should be used to treat them and for how long?

KQ 4: If GERD is suspected as the cause for chronic cough, what evaluations and diagnostic guidelines would best determine the cause of cough?

The investigators used CHEST Expert Cough Panel’s protocol, the American College of Chest Physicians (CHEST) methodologic guidelines and Grading of Recommendations Assessment, Development and Evaluation (GRADE) framework to answer the 4 KQs, and used systematic reviews and randomized controlled trials to generate recommendations and suggestions based on the evidence presented for each. Suggestions replaced recommendations when evidence was insufficient. The following recommendations and suggestions were formulated for children aged ≤14 years with chronic cough who did not have underlying lung disease.

  • In the absence of clinical features of GER such as recurrent regurgitation, dystonic neck posturing in infants, or heartburn/epigastric pain in older children, GERD treatment(s) should not be used to treat chronic cough (recommendation).
  • In children who have symptoms, signs, or tests that reflect gastroesophageal pathologic reflux, GERD treatment adhering to evidence-based GERD guidelines is recommended (recommendation).
  • In children who have symptoms, signs, or tests that reflect gastroesophageal pathologic reflux, acid suppressive therapy should not be used only to treat chronic cough (recommendation).
  • Children with gastrointestinal GER symptoms should be treated for GERD for 4 to 8 weeks in accordance with evidence-based GERD guidelines with a response reevaluation (suggestion).
  • If GERD is the suspected cause based on GER symptoms, evaluation should follow GERD guidelines.

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“Given the controversies relating chronic cough to GERD, we limited our review to systematic reviews and [randomized controlled trials],” the authors noted.

“The workup suggested by GERD guidelines is largely dependent on the child’s age and constellation of symptoms,” added the investigators.

“The optimal duration of various interventions to treat cough associated with GERD in infants…and children should be delineated. How to best define clinically important reflux-cough or cough-reflux episodes…and its severity…should be systematically and objectively evaluated,” the authors wrote.

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Reference

Chang AB, Oppenheimer JJ, Kahrilas PJ, et al. Chronic cough and gastroesophageal reflux in children: CHEST guideline and expert panel report [published April 16, 2019]. Chest. doi:10.1016/j.chest.2019.03.035