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Chronic Cough and Gastroesophageal Reflux in Children: CHEST Guideline and Expert Panel Report
Anne B Chang1, John J Oppenheimer2, Peter J Kahrilas3
1Division of Child Health, Menzies School of Health Research, Darwin, Northern Territory, Australia; Respiratory and Sleep Department, Queensland Children's Hospital, Queensland University of Technology, Brisbane, QLD, Australia.
Insights
Empirical treatment for gastroesophageal reflux disease (GERD) is not recommended for children with chronic cough unless they have GERD symptoms. Pediatric GERD guidelines should direct investigations and treatment.
Area of Science:
- Pediatric Pulmonology
- Gastroenterology
Background:
- The link between gastroesophageal reflux (GER) or GER disease (GERD) and chronic cough in children remains debated.
- Four systematic reviews were conducted using the PICO format to address this controversy.
Purpose of the Study:
- To determine the efficacy of empirical GERD treatment in children with chronic cough and no GERD symptoms.
- To assess if GERD treatment resolves cough in children with GERD symptoms.
- To identify optimal GER-based therapies and diagnostic approaches for GERD-induced chronic cough in children.
Main Methods:
- Systematic reviews adhering to CHEST Expert Cough Panel protocols and guidelines.
- Utilized the GRADE framework and Delphi methodology for consensus.
- Limited number of randomized controlled trials available for analysis.
Main Results:
- No significant difference in cough resolution was found between GERD interventions and placebo.
- Proton pump inhibitors were associated with increased serious adverse events compared to placebo.
- Qualitative data aligned with existing international GERD guidelines.
Conclusions:
- Empirical GERD treatment should not be initiated in children lacking clinical features of GERD.
- Existing pediatric GERD guidelines are recommended for managing investigations and treatment.
Background:
Whether gastroesophageal reflux (GER) or GER disease (GERD) causes chronic cough in children is controversial. Using the Population, Intervention, Comparison, Outcome (PICO) format, we undertook four systematic reviews. For children with chronic cough (> 4-weeks duration) and without underlying lung disease: (1) who do not have gastrointestinal GER symptoms, should empirical treatment for GERD be used? (2) with gastrointestinal GER symptoms, does treatment for GERD resolve the cough? (3) with or without gastrointestinal GER symptoms, what GER-based therapies should be used and for how long? (4) if GERD is suspected as the cause, what investigations and diagnostic criteria best determine GERD as the cause of the cough?
Methods:
We used the CHEST Expert Cough Panel's protocol and American College of Chest Physicians (CHEST) methodological guidelines and GRADE (Grading of Recommendations Assessment, Development and Evaluation) framework. Delphi methodology was used to obtain consensus.
Results:
Few randomized controlled trials addressed the first two questions and none addressed the other two. The single meta-analysis (two randomized controlled trials) showed no significant difference between the groups (any intervention for GERD vs placebo for cough resolution; OR, 1.14; 95% CI, 0.45-2.93; P = .78). Proton pump inhibitors (vs placebo) caused increased serious adverse events. Qualitative data from existing CHEST cough systematic reviews were consistent with two international GERD guidelines.
Conclusions:
The panelists endorsed that: (1) treatment(s) for GERD should not be used when there are no clinical features of GERD; and (2) pediatric GERD guidelines should be used to guide treatment and investigations.
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