Reasoning GP · Algorithm · 1-page summary
Cough in children (0–12 years)
For: children aged 0–12 with cough in primary care. Not for: adults (use the acute or chronic cough algorithm); ongoing asthma care and pertussis contacts (use the children's asthma and whooping cough protocols).
Core rule: most childhood cough is viral and improves within 3–4 weeks, so no tests or antibiotics. Your job is to find the airway emergency, the infant at risk of apnoea, pneumonia and the chronic wet cough. A normal SaO₂ does not rule out significant illness.
0Stop — call 999 now — do not delay transfer to give oral medication
- Apnoea, cyanosis or respiratory arrest; severe distress with exhaustion, reduced consciousness or unable to speak or feed; persistent hypoxia → 999
- Stridor at rest with significant recession, cyanosis, exhaustion or altered consciousness, or suspected epiglottitis / bacterial tracheitis (toxic, drooling, muffled voice, tripod posture) → 999. Do NOT examine the throat; keep the child calm.
- Severe asthma: too breathless to talk or feed, silent chest, poor respiratory effort, exhaustion → 999
- Inhaled foreign body with ongoing airway compromise → 999; back blows if conscious and choking.
1Triage by duration and character — (NG120)
| Cough | Think |
|---|---|
| Acute | Viral URTI (most common), croup, bronchiolitis, pneumonia, pertussis, foreign body, asthma |
| Prolonged 3–4 wk | Post-infectious (most common), pertussis, mycoplasma, early asthma |
| Daily >4 weeks | Wet → PBB, bronchiectasis, CF, ciliary dyskinesia, aspiration, foreign body, immunodeficiency, TB |
| Barking | Croup (stridor). Paroxysmal ± whoop → pertussis, whatever the vaccination status |
2Screen — one row is enough
- Stridor at rest (moderate croup) → Same-day
- Pertussis in an infant <6 months, or any infant with apnoea or cyanosis → Same-day hospital. Notify UKHSA.
- Choking, no complete obstruction → Same-day ED. Haemoptysis → Same-day
- Pneumonia with hypoxia, significant distress or systemic illness; moderate asthma not responding to bronchodilator → Same-day ED
- Bronchiolitis: apnoea, grunting, marked recession or RR >70 → 999. SaO₂ persistently <90% (≥6 weeks) or <92% (<6 weeks or comorbidity) → Same-day. Consider referral: SaO₂ <92%, RR >60, intake ~50–75%, dehydration, age <3 months.
- Chronic wet cough with clubbing, faltering growth, haemoptysis or hypoxia; recurrent pneumonia; suspected bronchiectasis → Same-day paediatrics
3Assess — only once blocks 0–2 are answered
☐ RR for a full minute, by age ☐ SaO₂, paediatric probe ☐ Recession, grunting, feeding, hydration ☐ Asymmetry (foreign body) ☐ Growth centiles, clubbing
No routine CXR or bloods in viral cough or bronchiolitis. Targeted CXR: focal signs, suspected foreign body, wet cough ≥4 weeks, haemoptysis, clubbing.
4Classify — only if the screen is negative
- Bronchiolitis — usually <2 years; coryza, then cough, tachypnoea or recession, wheeze or crackles.
- Croup — barking cough, hoarse voice; mild if no stridor at rest → oral dexamethasone.
- Pneumonia — fever, focal crackles, tachypnoea, hypoxia; often a clinical diagnosis.
- Pertussis — paroxysms, whoop, post-tussive vomiting, infant apnoea; can occur despite vaccination.
- Asthma — never from cough alone, nor from wheeze under 1. Age 5–16: FeNO first where available, then spirometry. Under 5: consider an 8–12 week ICS trial.
- Uncertain, or wet cough >4 weeks — say so and reassess; PBB is not confirmed by response to antibiotics.
5Treat today — doses: NICE/SPC, BNFC, local formulary
- Viral cough: no antibiotic; honey at night if >1 year (not infants); no OTC cough medicines under 6 (6–12 on pharmacist advice only); fluids, analgesia.
- Mild croup: single dose of oral dexamethasone (local paediatric dose); can go home. Acute wheeze: salbutamol MDI + spacer per the local acute-asthma pathway.
- Bronchiolitis: small frequent feeds, nasal saline; no routine antibiotics, bronchodilators or steroids; written safety-net.
- Pertussis: azithromycin or clarithromycin (clarithromycin under 1 month) within 14 days of onset, 21 days if a priority group 1 contact; notify UKHSA.
6Refer routinely
- Suspected CF or aspiration in a well child; wet cough persisting or recurring after a course, or >1 course → Urgent paediatrics. No repeated empirical antibiotics.
- Daily cough >4 weeks undiagnosed, asthma uncontrolled at step 3+ or uncertain under 5, suspected ciliary dyskinesia → paediatric outpatients.
- Habit cough (honking, gone in sleep) → CAMHS or specialist respiratory.
7Never reassure by
- A normal SaO₂, or a single respiratory-rate reading in isolation.
- A normal CXR when foreign-body suspicion is high.
- No whoop, or full vaccination: infants may only have apnoea.
- Improvement on antibiotics: it does not confirm PBB.
- A normal newborn CF screen in chronic wet cough with faltering growth.
- Settling a very worried parent without reassessing the child.
8Safety-net — say it, then document it
999 “Call 999 if your child stops breathing or turns blue, is struggling to breathe — grunting, sucking in under the ribs, too breathless to talk or feed — has wheeze not helped by salbutamol, collapses, is floppy or can't be woken, or noisy breathing in at rest gets worse.”
Same day “Most coughs clear in 3 to 4 weeks. Contact us today if the cough suddenly gets much worse, they have noisy breathing in at rest, feed much less than usual, have a dry nappy for 12 hours or more, or you are very worried.”
✓Safe to leave primary care only if — all five, documented
No block 0–2 row applies
RR, SaO₂, work of breathing, feeding and hydration recorded
One cause named, or uncertainty stated
Pertussis notified; review or referral owner and date set
Safety-net given (written for bronchiolitis)
Summary of the full Reasoning GP cough in children algorithm, which holds the detail, examination, investigations, asthma ladder and evidence. Sources: NICE NG120, NG9, NG245 (with BTS and SIGN), NG250; BTS/SIGN 158; UKHSA pertussis guidance; MHRA. Clinical reference — follow local paediatric pathways and check doses in the current BNFC.