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Cough is a common reason for pediatric visits. When should bronchitis be on the diagnostic radar?
Cough is one of the top reasons for outpatient pediatric visits, accounting for nearly 30 million visits each year in the United States alone.1 There are lots of varieties when it comes to cough—acute, chronic, bacterial, viral—and viral upper respiratory infections are mostly to blame.
One diagnosis that is often associated with cough in adults—both acute and chronic bronchitis—is rarely found in the pediatric population, according to Jeffrey S. Gerber, MD, PhD. Gerber is an attending physician in the Division of Infectious Diseases and medical director of the Antimicrobial Stewardship Program at Children’s Hospital of Philadelphia in Pennsylvania. Children are highly susceptible to acute respiratory infections in general, but the cause is often left underdetermined because many cases resolve on their own. “Bronchitis is rarely used as a diagnosis, and, when it is, the recommendation has always been no antibiotics in otherwise healthy children,” Gerber said.
The “no antibiotics” stance may be firm in research, but the battle can be difficult in the outpatient setting, as parents continue to worry about which bacteria or virus is making their child sick. In the COVID-19 climate, these concerns could be escalated.
The cause of the cough
Upper respiratory infections are a major cause of illness, hospitalization, and death in young children, and many viruses are to blame.2 Acute viral bronchitis is generally treated with supportive care, so testing may not take place, especially in short-term, mild, or acute childhood cases.
In cases of bacterial bronchitis—a top cause of wet cough in children— both US and European experts recommend antibiotics. Most often, this involves a 2-week course of amoxicillin–clavulanate, although a 4-week course has been more recently investigated with positive results.3
Fungal infections that lead to chronic cough are another possibility, but this is a distinct condition for which treatment methods are still being debated.4
In a world still reeling from the pandemic, there may be questions as to how cough in children is diagnosed, especially as COVID-19 continues to circulate, and many children still remain unvaccinated.
Assessing bronchitis in children
Chronic bronchitis is suspected even less often than acute bronchitis in children. The chronic type is usually linked to adult behaviors like smoking, but children who have a lasting cough may be considered for this diagnosis. Findings of a new study investigating prevalence of chronic bronchitis in young adults reveal an overall prevalence of 5.5%.
Among the young adults in the study who received a diagnosis of chronic bronchitis, 37% were smokers; other identified risk factors included the following5:
Debating the differentials
During COVID-19, it seems that any cough can strike fear of this infection, and clinicians could become overconfident—or underconfident— of their ability to accurately diagnose what is causing a cough. COVID-19 and bronchitis share several symptoms, so it takes a careful assessment, as well as perhaps some imaging studies or laboratory work, to definitively diagnose either.
As difficult as it can be for clinicians to distinguish between these conditions, it can be even harder for parents. Even before the COVID-19 pandemic began, emergency department visits for cough were on the rise.9 There are little data that compare how few children were treated for cough during the period that COVID-19 raged, but as the United States approaches another cold and flu season, it is important to review symptoms and plans with parents to help them differentiate between illnesses such as influenza, bronchitis, and COVID-19.
What about this winter?
There is no good way to track how most viruses will circulate in the months ahead, but Gerber offers guidance for clinicians ahead of the post-COVID-19 cold, season, especially when it comes to assessing respiratory infections.
“The post COVID-19 world will likely be somewhat different,” Gerber said. “There are 2 themes that might influence patient and clinician experiences with respiratory viruses. First, many people have come to understand how most respiratory viruses are passed from one person to another.”
That knowledge could help influence the precautions people take as season viruses that cause illnesses such as bronchitis begin to circulate. People might also become more judicious in how they interact with others when sick and how they protect themselves from getting sick, according to Gerber: “I’m not saying we should put on masks at the first sound of a cough or the first day of winter; I’m just speculating that it might happen.”
Second, Gerber said, much has been learned about viruses because of COVID-19, and, hopefully, this first-hand knowledge will better support what research has suggested for years.
“We have all just gotten a crash course in 1 critical difference between viruses, which cause the vast majority of upper respiratory infections, and bacteria, which cause many fewer: Antibiotics don’t work on viruses. Hopefully, this will stick,” Gerber says.
1. Kasi AJ, Kamerman-Kretzmer RJ. Cough. Pediatr Rev. 2019;40(4):157.167. doi:10.1542/pir.2018-0116
2. Lei C, Yang L, Lou CT, et al. Viral etiology and epidemiology of pediatric patients hospitalized for acute respiratory tract infections in Macao: a retrospective study from 2014 to 2017. BMC Infect Dis. 2021;21(1):306. doi:10.1186/s12879-021-05996-x
3. Ruffles TJC, Goyal V, Marchant JM, et al. Duration of amoxicillin-clavulanate for protracted bacterial bronchitis in children (DACS): a multi-centre, double blind, randomized controlled trial. Lancet Respir Med. 2021;S2213-2600(21):00104-1. doi:10.1016/S2213-2600(21)00104-1
4. Ozyigit LP, Monteiro W, Rick EM, Satchwell J, Pashley CH, Wardlaw AJ. Fungal bronchitis is a distinct clinical entity which is responsive to antifungal therapy. Chronic Respir Dis. 2021:18:1479973120964448. doi:10.1177/1479973120964448
5. Wang G, Hallberg J, Bergström PU, et al. Assessment of chronic bronchitis and risk factors in young adults: results from BAMSE. Eur Respir J. 2021;57(3):2002120. doi:10.1183/13993003.02120-2020
6. Acute Bronchitis in Children. Stanford Children’s Hospital. Accessed June 29, 2021. https://www.stanfordchildrens.org/en/topic/default?id=acute-bronchitis-in-children-90-P02930
7. Information for pediatric healthcare providers. Centers for Disease Control and Prevention. Updated December 30, 2020. Accessed June 29, 2021. https://www.cdc.gov/coronavirus/2019-ncov/hcp/pediatric-hcp.html
8. Flu & young children. Centers for Disease Control and Prevention. Accessed June 29, 2021. https://www.cdc.gov/flu/highrisk/children.htm?web=1&wdLOR=c75CBFCF7-43B9-0447-BC79-BC14D4F2269D
9. Elmore JG, Wang PC, Kerr KF, et al. System in the months prior to the COVID-19 pandemic: time-series analysis. J Med Internet Res. 2020;22(9). doi:10.2196/21562