Avoid reflux therapies for chronic cough in children: new guidelines


By Michael Woodhead

30 Apr 2019

Anti-reflux medications such as proton pump inhibitors have little or no value in the management of chronic cough in children, according to new expert guidelines.

An update to 2006 CHEST Pediatric Cough guideline, led by Professor Anne Chang of the Menzies School of Health Research in Darwin, concludes that a 4-8 week trial of treatment such as PPI may only be warranted in children with chronic cough who have symptoms of gastro-oesophageal reflux disease (GORD).

After conducting a series of systematic reviews of randomised controlled trials, the CHEST Expert Cough Panel found there was little evidence to address the question of whether treatment of GORD would help resolve chronic cough in children.

A meta-analysis of two RCTs showed no significant difference between the GORD treatment vs. placebo for cough resolution, and also noted that PPIs caused increased serious adverse events.

The group therefore concluded that treatments for GORD should not be used to treat chronic cough (>4 weeks) in children under 14 when there are no clinical features of reflux such as recurrent regurgitation, dystonic neck posturing in infants, or heartburn/epigastric pain in older children.

And even when children with chronic cough have symptoms of GORD the guidelines recommend that anti-reflux treatment only be used for management of these symptoms rather than solely as a treatment for chronic cough.

The treatment for GORD should be tailored to a child’s age, with approaches such as more frequent feeds and thickeners preferred in infants, the guidelines advise.

“The agent used for the ‘trial of treatment’ approach is dependent on the child’s age, feeding regime and symptoms. PPIs and H2 Receptor Antagonists should not be used for longer than 4-8 weeks without further evaluation,” they recommend.

If GORD is suspected in children with chronic cough they should be investigated according to current reflux guidelines, that include approaches such a endoscopy and pH-metry, they add.

“It … remains unclear whether treatments for GORD resolve chronic cough in children. Possible treatment adverse events need to be balanced with possible efficacy and there is increasing evidence of the overuse and adverse events related to PPI use, such as increased risk of infections, vitamin B12 deficiency and bone fractures,” the authors note.

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