Pediatric otolaryngologic manifestations of gastroesophageal reflux disease

Mild-to-Moderate Croup Presentations in Patients With COVID-19 Infection

This case series will describe two pediatric patients, aged nine months and two years, who presented to the emergency department with symptoms of croup. However, they were later found to have coronavirus disease 2019 (COVID-19). The two patients had no pre-existing medical conditions, and they were treated with steroids and nebulized epinephrine as required. They were discharged home with instructions to follow up with their primary care provider and to follow isolation guidelines. This report will illustrate how upper respiratory symptoms, including those consistent with croup, can be associated with or caused by an existing COVID-19 infection. More research is needed to determine if this association can lead to more long-term complications of COVID-19. Additionally, testing for COVID-19 should be incorporated into the assessment and management of this presentation. By recognizing this, clinicians can identify the cause of the illness sooner and initiate targeted treatment more effectively.

Co-occurrence of childhood functional constipation and gastroesophageal reflux disease (GERD)

Objective

Functional constipation (FC) and Gastroesophageal Reflux Disease (GERD) are common gastrointestinal disorders in children. The aim of this study is to investigate the correlation between functional constipation and GERD in children.

Methods

In this cross-sectional study, a total of 82 children aged <16 years who referred to the pediatric gastroenterology clinic of (XXX) and were diagnosed with functional constipation according to ROME III criteria, and gastroesophageal reflux disease according to clinical history and DeMeester Score. Questionnaire was used to obtain the data regarding age, sex, cause of the visit, presence or absence of any symptom was noted, clinical examinations and difficulty in defecation.

Results

Of the 82 children with FC and GERD, 45 were boys and 37 were girls. Among children with FC and GERD, FC was reported in 50 (61%) cases prior to the onset of GERD, whereas 32 (39%) of the children had reflux before FC. The mean age of participants presented with FC was 5.66 ± 3.52 and that of GERD was 5.24 ± 2.83. The difference in mean age was not statistically significant. Of the children with gastroesophageal reflux disease, there were 13 (40.6%) males and 19 females while 32 (64%) males and 18 females had FC and the gender-based difference was statistically significant between the 2 groups.

Conclusion

The prevalence of functional constipation in children was higher than gastroesophageal reflux disease. Gastroesophageal reflux disease and functional constipation should be simultaneously considered for therapeutic interventions and patients with functional digestive diseases should be monitored and followed-up.

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FC and GERD are common gastrointestinal disorders in children.

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The prevalence of functional constipation in children was higher than gastroesophageal reflux disease.

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Gastroesophageal reflux and functional constipation should be considered for therapeutic.

Medical and psychiatric differential diagnoses of pediatric globus sensation: A case study with review discussion

Globus hystericus, also known as globus pharyngeus or globus sensation, is characterized by the physical sensation of a mass in one's throat. Globus sensation is more common in adults and reported more rarely in children. Adult patients with globus sensation score higher on neuroticism, introversion, anxiety, and depression. However, not all patients with globus sensation have psychiatric abnormalities. Thus, it is important to share an atypical presentation in children and highlight the necessity of ruling out other organic causes. The present case study elucidates the process of ruling out medical etiologies of globus sensation in a young girl with anxiety and food aversion. We provide a review discussion of the differential diagnoses, both medical and psychiatric, of globus sensation in the pediatric population reported in past literature. The case study and review of pediatric globus sensation shows that the symptom can be associated with a wide array of psychological and medical diagnoses. The medical differential diagnoses of globus sensation include the gastroenteric system, laryngeal system, cardiovascular system, and nervous system. We encourage critical analysis of other potential diagnoses, given each patient's unique history and physical presentation.

Stridor in children

Several conditions that manifest as stridor can mimic asthma. When there is an initial failure in therapy, other diagnoses should be considered. The absence of witnessed choking does not exclude an inhaled/ingested foreign body. http://ow.ly/bqRD30kJcgI.

Prevalence and Epidemiological Characteristics of Endoscopically Proven Reflux Esophagitis in Children in Korea

PURPOSE

The prevalence of reflux esophagitis (RE) has increased recently in Korea. Little is known concerning the prevalence and characteristics of RE in pediatric patients. This study investigated the prevalence and influence of risk factors in endoscopically proven RE in Korea in pediatric patients over a period of 14 years.

METHODS

A retrospective chart review of all patients between the ages of 1 month and 20 years who underwent esophagogastroduodenoscopy at Samsung Medical Center between 2001 and 2014 was carried out. Univariate and multivariate analyses were conducted to identify independent risk factors for RE.

RESULTS

The prevalence rate of endoscopically proven RE in this study was 28.7% (978/3,413). The prevalence of RE increased from 11.8% from 2001 to 2007 to 37.7% from 2008 to 2014. Multivariate logistic regression analysis revealed that residency in the Greater Gangnam area (odds ratio [OR], 1.21; 95% confidence interval [CI], 1.02-1.44) and age (OR, 1.13; 95% CI, 1.11-1.15) were significant predictive factors for the presence of RE.

CONCLUSION

The prevalence rate of endoscopically proven pediatric RE has increased over the past 14 years. Residency and older age are more important independent risk factors for pediatric RE in Korea.

Evaluation of 563 children with chronic cough accompanied by a new clinical algorithm

BACKGROUND

This study aims to evaluate the children with chronic cough and to analyze their etiological factors according to the age groups.

METHOD

Five hundred sixty-three children with chronic cough were included. The last diagnosis were established and were also emphasized according to the age groups.

RESULTS

The mean age was 5.4 ± 3.8 years (2-months-17-years) and 52 % of them were male. The most common final diagnosis from all the participants were: asthma (24.9 %), asthma-like symptoms (19 %), protracted bacterial bronchitis (PBB) (11.9 %), and upper airway cough syndrome (9.1 %). However, psychogenic cough was the second most common diagnosis in the subjects over 6 years of age.

CONCLUSION

Asthma and asthma-like symptoms were the most common diagnosis in children. Different age groups in children may have a different order of frequencies. Psychogenic cough should be thought of in the common causes especially in older children.

The assessment and management of chronic cough in children according to the British Thoracic Society guidelines: descriptive, prospective, clinical trial

BACKGROUND

Chronic cough is a common problem of various etiologies. While diagnosis may relatively be easy in the presence of some specific findings, it tends to be rather difficult when there are no clear symptoms. Therefore, practical guidelines are needed for management of patients with chronic cough. We aimed to evaluate assessment and management of chronic cough in children according to the British Thoracic Society guidelines published in 2008.

METHODS

Patients with chronic cough lasting longer than 8 weeks between 5 and 16 years old were evaluated. Pulmonary function test and chest radiography were performed on all patients. Further workup was conducted on those requiring further investigation. Patients were re-evaluated at 2- to 4-week intervals, and we followed our patients for 18 months until cough resolved.

RESULTS

One hundred fifty six patients (52.5% female) aged 5-16 (8.42 ± 2.6) years were included. Of the 156 patients, 19.2% (n = 30) were diagnosed with postnasal drip syndrome plus asthma; 18.6% (n = 29) with postnasal drip syndrome; 12.2% (n = 19) with asthma; 12.2% (n = 19) with protracted bacterial bronchitis; and 11.5% (n = 18) with nonspecific isolated cough, 9.6% (n = 15) with cough variant asthma, 5.7% (n = 9) with psychogenic cough and 3.2% (n = 5) with gastroesophageal reflux disease.

CONCLUSIONS

Postnasal drip syndrome and asthma was the most common cause of chronic cough. Asthma-associated findings were found in some of the patients diagnosed with postnasal drip syndrome. It has been observed that there could be more than one particular cause for cough concerning some patients. The gastroesophageal reflux disease was not a common primary cause of chronic cough in children.

Chronic rhinosinusitis and age: is the pathogenesis different?

Chronic rhinosinusitis (CRS) is a common disease with a significant impact on quality of life, which is seen across all age groups. There are differences in symptomatology, histopathology and associated diseases when comparing pediatric versus adult patients with CRS. Nasal polyposis tends to be less commonly seen in pediatric CRS compared with adults except in children with cystic fibrosis or allergic fungal rhinosinusitis. The differences in histopathology of CRS in different age groups include higher cellularity and more prominent lymphocytic infiltration in children compared with adults who tend to have a stronger eosinophilic infiltration and more prominent glandular hyperplasia. There are data supporting a stronger association of gastroesophageal reflux disease and otitis media with CRS in children compared with adults. Adenoids may play a role in pediatric, but not adult CRS. Immunodeficiencies and asthma are strongly associated with CRS in all age groups. There is a paucity of data on pathophysiology of disease on elderly CRS.

Gastroesophageal reflux as a predictor of complications after adenotonsillectomy in young children

OBJECTIVE

To examine characteristics of young children with gastroesophageal reflux (GER) who experienced complications within the first 24h after adenotonsillectomy.

STUDY DESIGN

Subset analysis of a larger retrospective cohort.

METHODS

A retrospective chart review was performed at a tertiary care children's hospital. Consecutive records of children 3 years old and younger undergoing adenotonsillectomy (AT) over a 5-year period were reviewed. Children with a clinical history of GER were selected for the study.

RESULTS

993 children were included in the initial analysis, and GER was found to be a significant independent variable predictive of early complications. 81 children with a history of GER were included in this study and 8 (9.9%) were found to have experienced complications within the first 24h. Six of the complications were airway-related; two required re-intubation within the first 24h. All 8 children with complications had symptoms of sleep-disordered breathing and two had documented severe obstructive sleep apnea (AHI 18.6 and 27.2). Seven children had other risk factors for complications after AT. Eighteen (22%) children had a prolonged length of stay (range 2-7 days); additional risk factors were present in these patients as well.

CONCLUSIONS

Knowledge of risk factors for complications following adenotonsillectomy is critical for identifying at-risk patients that may warrant closer post-operative observation. GER has been previously identified as a risk factor for complications in young children. Upon closer analysis, young children with GER who have other known risk factors may be at a further increased risk for airway complications and prolonged hospitalization. Parents of these children can be counseled on the post-operative risks and the possibility of a longer hospitalization.

Rhinosinusitis in children

Rhinosinusitis is the inflammation of the mucous membranes of nose and paranasal sinus(es). 5-13% of upper respiratory tract infections in children complicate into acute rhinosinusitis. Though not life threatening, it profoundly affects child's school performance and sleep pattern. If untreated, it could progress to chronic rhinosinusitis (CRS). The pathogens involved in perpetuation of CRS consist of multidrug-resistant mixed microflora. CRS is challenging to manage and could further extend to cause eye or intracranial complications. In children, CRS diagnosis is often either missed or incomprehensive. Due to this, morbidity and strain on healthcare budget are tremendous. Flexible fiberoptic endoscopy has revolutionized management of CRS. Its utility in children is being increasingly recognized. Optimal management entails specific appropriate antimicrobials as well as treatment of underlying causes. The aim is to normalize sinus anatomy and physiology and regain normal mucociliary function and clearance.

The diagnosis and management of globus: a perspective from Belgium

PURPOSE OF REVIEW

There is no standard protocol for managing globus pharyngeus. Checking the recent developments in this field regularly is of paramount importance.

RECENT FINDINGS

The commonest symptoms for which proton pump inhibitors are prescribed are globus (73%), followed by choking episodes (66%) and chronic cough (62%). Opinions remain divided about the role of upper esophageal sphincter hypertonicity in globus sensation. Upper aerodigestive tract malignancy is rare and must be excluded. Hypertrophy of the base of the tongue, heterotopic gastric mucosa, curled epiglottis, thyroid enlargement, rare benign or malignant tumors of the pharynx, excessive tension and Eagle's syndrome are possible causes. Flexible endoscopy is a frequently used examination, but there is a 'blind zone' under any upper aerodigestive tract malignancy, requiring rigid endoscopy for some indications. Barium swallow pharyngoesophagography should not be requested systematically for cancer detection. Dual-probe 24 h pH monitoring can help in the diagnosis of reflux. Impedance recording can be useful for the detection of acidic and nonacidic liquid and mist reflux events. Manometric measurements are consistent. Laryngopharyngeal symptoms, such as throat clearing, hoarseness, cough, and globus pharyngeus, are slower to resolve than esophageal symptoms. Nocturnal recovery of gastric acid secretion was demonstrated even with proton pump inhibitors. The symptoms disappeared with an additional H2 receptor antagonist.

SUMMARY

More awareness is required for patients complaining of globus pharyngeus.

Systematic review: the extra-oesophageal symptoms of gastro-oesophageal reflux disease in children

BACKGROUND

Extra-oesophageal symptoms are thought to be common, atypical symptoms of gastro-oesophageal reflux disease (GERD) in children.

AIM

To investigate the prevalence of GERD in children with extra-oesophageal symptoms or of extra-oesophageal symptoms in children with GERD, and the effect of GERD therapies on extra-oesophageal symptoms.

METHODS

A systematic review of articles in PubMed and EMBASE.

RESULTS

We identified 18 relevant articles. The pooled weighted average prevalence of GERD in asthmatic children was 23%, compared with 4% in healthy controls from the same five studies. The majority of studies evaluating the relationship between apparent life-threatening event (ALTE) and GERD did not suggest a causal relationship. Seven studies reported that respiratory symptoms, sinusitis and dental erosion were significantly more prevalent in children with GERD than in controls. Data from pharmacotherapeutic trials were inconclusive and provided no support for a causal relationship between GERD and extra-oesophageal symptoms.

CONCLUSIONS

Possible associations exist between GERD and asthma, pneumonia, bronchiectasis, ALTE, laryngotracheitis, sinusitis and dental erosion, but causality or temporal association were not established. Moreover, the paucity of studies, small sample sizes and varying disease definitions did not allow firm conclusions to be drawn. Most trials of GERD therapies showed no improvement in extra-oesophageal symptoms in children.

Abnormal Sensorimotor Integrative Function of the Larynx in Congenital Laryngomalacia: A New Theory of Etiology

OBJECTIVES/HYPOTHESIS

Laryngomalacia is an enigmatic disease in which laryngeal tone is weak, resulting in dynamic prolapse of tissue into the larynx. Sensorimotor integrative function of the brainstem and peripheral reflexes are responsible for laryngeal tone and airway patency. The goal of this study was to elucidate the etiology of decreased laryngeal tone through evaluating the sensorimotor integrative function of the larynx. The secondary goal was to evaluate factors and medical comorbidities that contribute to the wide spectrum of symptoms and outcomes.

STUDY DESIGN

Prospective and retrospective collection of evaluative data on infants with congenital laryngomalacia at two tertiary care pediatric referral centers.

METHODS

Two hundred one infants with laryngomalacia were divided into three groups on the basis of disease severity (mild, moderate, severe). Patients were followed prospectively every 8 to 12 weeks until symptom resolution or loss to follow-up. Sensorimotor integrative function of the larynx was evaluated in 134 infants by laryngopharyngeal sensory testing (LPST) of the laryngeal adductor reflex (LAR) by delivering a duration- (50 ms) and intensity- (2.5-10 mm Hg) controlled air pulse to the aryepiglottic fold to induce the LAR. Medical records were retrospectively reviewed for medical comorbidities.

RESULTS

The initial LPST was higher (P < .001) in infants with moderate (6.8 mm Hg) and severe disease (7.4 mm Hg) compared with those with mild disease (4.1 mm Hg). At 1, 3, and 6 months, infants with moderate and severe disease continued to have a higher LPST compared with those with mild disease. At 9 months, the LPST decreased in all subjects (3.1-3.5 mm Hg, P = .14), which also correlated with symptom resolution. Neurologic, genetic, and cardiac diseases were more common in infants with severe disease (P < .001). Gastroesophageal reflux disease (GERD) and feeding problems more common in those with moderate and severe disease (P < .001). Apgar scores were lower in those with severe disease (P < .001). Most symptoms resolved within 12 months of presentation. Those with GERD benefited from treatment. Supraglottoplasty resulted in few complications. Multiple comorbidities (>3) influenced the need for tracheotomy.

CONCLUSIONS

Laryngeal tone and sensorimotor integrative function of the larynx is altered. The degree of alteration correlated with disease severity, indicating that factors that alter the peripheral and central reflexes of the LAR have a role in the etiology of signs and symptoms of laryngomalacia. GERD, neurologic disease, and low Apgar scores influenced disease severity and clinical course, explaining the spectrum of disease symptoms and outcomes. Sensorimotor integrative function improved as symptoms resolved.

Evaluation of chronic cough in children

Chronic cough in children is among the problems that lead to frequent consultations with a doctor. In this study, we attempted to research the reasons for chronic cough by an evaluation method using the guidelines that were suggested for children by the American College of Chest Physicians (ACCP) in 2006. We studied 108 children between 6 and 14 years of age who had a cough that lasted for > 4 weeks. The patients were reevaluated during the second to fourth weeks, and until either the cough terminated or resolved. Twenty-five percent of the patients received diagnoses of asthma and asthma-like symptoms, 23.4% received diagnoses of protracted bronchitis, 20.3% received diagnoses of upper airway cough syndrome (UACS), and 4.6% received diagnoses of gastroesophageal reflux disease. Asthma and asthma-like symptoms, protracted bronchitis, and UACS were detected in order of frequency as the reason for chronic cough in children. We concluded that the 2006 ACCP guidelines for the management of chronic cough in children are effective and can be successfully utilized in a nonaffluent study setting.

Prevalence of endoscopic findings of erosive esophagitis in children: a population-based study

PURPOSE

Symptoms of gastroesophageal reflux disease (GERD) occur in 2% to 7% of children. The manifestations of GERD can be limited to symptoms (eg, heartburn, regurgitation) or can be more complicated, such as erosive esophagitis, esophageal strictures, or Barrett esophagus. The prevalence of such GERD complications in children is unknown. The purpose of this study was to determine the prevalence of endoscopic findings of erosive esophagitis in children.

PATIENTS AND METHODS

All children ages 0 to 17 years, 11 months who underwent upper endoscopy that was recorded in the Pediatric Endoscopic Database System-Clinical Outcomes Research Initiative between 1999 and 2002 were included. Endoscopic reports that were incomplete or that did not include demographic features, indications for endoscopy, or endoscopic findings were excluded. Erosive esophagitis was defined either descriptively or by the Los Angeles classification. Esophageal biopsy was not evaluated.

RESULTS

A total of 7188 children who underwent upper endoscopy fulfilled the inclusion and exclusion criteria. Of those, 888 (12.4%) had erosive esophagitis. The median age of children with erosive esophagitis was 12.7 +/- 4.9 years versus 10.0 +/- 5.1 years in those without erosive esophagitis (P <or= 0.0001). Of those with erosive esophagitis, 55.2% (490/888) were male, compared with 48.2% (3040/6300) in those without erosive esophagitis (P = 0.0001). Erosive esophagitis was found in 29 of 531 (5.5%) children ages 0 to 1 years and progressively increased to 106 in 542 individuals (19.6%) by age 17. Hiatal hernia was found in 68 (7.7%) of children with erosive esophagitis, compared with 157 (2.5%) without erosive esophagitis (P <or= 0.0001. The prevalence of Barrett esophagus, esophageal stricture, ulcer, previous surgery, nodules, foreign body or retained food, and anatomic abnormalities was not significantly different between children with erosive esophagitis and those without.

CONCLUSIONS

The frequency of erosive esophagitis is slightly higher in male children and increases with age. In contrast to erosive esophagitis in adults, there were no significant variations according to race or ethnicity. Hiatal hernia is the only endoscopic observation that predicts erosive esophagitis.

[Current management of acute pediatric rhinosinusitis in France]

Un groupe de médecins généralistes et multidisciplinaire de spécialistes contribue à définir les différentes formes de sinusites ou rhinosinusites aiguës de l'enfant à partir des principaux symptômes et signes cliniques. Le rôle des pathologies associées telles que l'allergie, les troubles immunitaires est envisagé. L'incidence, la présentation clinique et la prise en charge des complications sont présentées. Les indications des examens radiologiques et biologiques sont analysées. La prise en charge médicale en particulier, la place et le type des antibiotiques sont discutés. Des propositions de prise en charge selon des situations cliniques rencontrées en pratique sont présentées.

Rhinosinusitis in children

Clinical practice guidelines for the management of acute bacterial rhinosinusitis in children were published by the American Academy of Pediatrics in 2001. Changes in the antibiotic susceptibility patterns for the common pathogens causing both acute and chronic rhinosinusitis warrant a reevaluation and update of these recommendations. In addition, there was only a very brief discussion of chronic disease in this publication, with the conclusion that the pathogenesis and management of recurrent or prolonged infection were essentially unknown. Although there are still insufficient data in the literature to develop evidence-based clinical guidelines, a careful review of recent literature and the clinical experience of experts who manage pediatric chronic sinusitis are presented in an effort to provide some specific recommendations and to offer practical treatment options. Factors associated with chronic rhinosinusitis should be addressed individually and include environmental pollution, recurrent viral upper respiratory infections, allergic and nonallergic rhinitis, ciliary dyskinesia, cystic fibrosis, immunodeficiency, gastroesophageal reflux, and anatomic abnormalities.

Improved infant swallowing after gastroesophageal reflux disease treatment: a function of improved laryngeal sensation?

OBJECTIVE

The objective of this study was to describe improvements in pediatric swallowing after gastroesophageal reflux treatment.

STUDY DESIGN

The authors conducted a retrospective database and chart review at two tertiary care children's hospitals.

PARTICIPANTS

Patients (21 males, 7 females) ranged in age from 1 to 32 months. All patients had clinical evidence of gastroesophageal reflux disease (GERD) as well as evidence of dysphagia with aspiration (laryngeal vestibule and/or trachea) or hypopharyngeal pooling on flexible endoscopic evaluation of swallowing and sensation testing (FEESST) or videofluoroscopic swallow study (VSS).

INTERVENTION

Each child underwent either medical or surgical intervention for control of their GERD.

OUTCOME MEASURES

Outcome measures were change in laryngopharyngeal sensation and swallowing function with repeat swallow evaluation after GERD treatment.

RESULTS

A significant improvement in both swallow function and sensory testing was demonstrated after GERD treatment.

CONCLUSIONS

GERD may result in decreased laryngopharyngeal sensitivity, which may contribute to pediatric swallowing dysfunction. Control of GERD may improve swallow function. These findings have important clinical implications that need further study.

Guidelines for evaluating chronic cough in pediatrics: ACCP evidence-based clinical practice guidelines

OBJECTIVES

To review relevant literature and present evidence-based guidelines to assist general and specialist medical practitioners in the evaluation and management of children who present with chronic cough.

METHODOLOGY

The Cochrane, MEDLINE, and EMBASE databases, review articles, and reference lists of relevant articles were searched and reviewed by a single author. The date of the last comprehensive search was December 5, 2003, and that of the Cochrane database was November 7, 2004. The authors' own databases and expertise identified additional articles.

RESULTS/CONCLUSIONS

Pediatric chronic cough (ie, cough in children aged <15 years) is defined as a daily cough lasting for >4 weeks. This time frame was chosen based on the natural history of URTIs in children and differs from the definition of chronic cough in adults. In this guideline, only chronic cough will be discussed. Chronic cough is subdivided into specific cough (ie, cough associated with other symptoms and signs suggestive of an associated or underlying problem) and nonspecific cough (ie, dry cough in the absence of an identifiable respiratory disease of known etiology). The majority of this section focuses on nonspecific cough, as specific cough encompasses the entire spectrum of pediatric pulmonology. A review of the literature revealed few randomized controlled trials for treatment of nonspecific cough. Management guidelines are summarized in two pathways. Recommendations are derived from a systematic review of the literature and were integrated with expert opinion. They are a general guideline only, do not substitute for sound clinical judgment, and are not intended to be used as a protocol for the management of all children with a coughing illness. Children (aged <15 years) with cough should be managed according to child-specific guidelines, which differ from those for adults as the etiologic factors and treatments for children are sometimes different from those for adults. Cough in children should be treated based on etiology, and there is no evidence for using medications for the symptomatic relief of cough. If medications are used, it is imperative that the children are followed up and therapy with the medications stopped if there is no effect on the cough within an expected time frame. An evaluation of the time to response is important. Irrespective of diagnosis, environmental influences and parental expectations should be discussed and managed accordingly. Cough often impacts the quality of life of both children and parents, and the exploration of parental expectations and fears is often valuable in the management of cough in children.

Cough: are children really different to adults?

Worldwide paediatricians advocate that children should be managed differently from adults. In this article, similarities and differences between children and adults related to cough are presented. Physiologically, the cough pathway is closely linked to the control of breathing (the central respiratory pattern generator). As respiratory control and associated reflexes undergo a maturation process, it is expected that the cough would likewise undergo developmental stages as well. Clinically, the 'big three' causes of chronic cough in adults (asthma, post-nasal drip and gastroesophageal reflux) are far less common causes of chronic cough in children. This has been repeatedly shown by different groups in both clinical and epidemiological studies. Therapeutically, some medications used empirically for cough in adults have little role in paediatrics. For example, anti-histamines (in particular H1 antagonists) recommended as a front-line empirical treatment of chronic cough in adults have no effect in paediatric cough. Instead it is associated with adverse reactions and toxicity. Similarly, codeine and its derivatives used widely for cough in adults are not efficacious in children and are contraindicated in young children. Corticosteroids, the other front-line empirical therapy recommended for adults, are also minimally (if at all) efficacious for treating non-specific cough in children. In summary, current data support that management guidelines for paediatric cough should be different to those in adults as the aetiological factors and treatment in children significantly differ to those in adults.

Chronic sinusitis in children

Clinical practice guidelines for the management of acute sinusitis in children have been published by the American Academy of Pediatrics. Of note is that in this document, a brief discussion of chronic disease concluded that the pathogenesis and management are essentially unknown. Although there are insufficient data in the literature to develop evidence-based clinical guidelines, a careful review of the literature and clinical experience of experts who manage pediatric chronic sinusitis is presented in an effort to develop specific recommendations and to offer practical treatment options. Factors associated with chronic sinusitis should be addressed individually and include recurrent viral upper respiratory infections, allergic and nonallergic rhinitis, ciliary dyskinesia, cystic fibrosis, immunodeficiency, and anatomic abnormalities. Bacteriology includes the 3 pathogens associated with acute disease i.e., Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis but with chronic sinusitis also includes Staphylococcus aureus, anaerobic bacteria, and fungi. Medical interventions discussed include endoscopic sinus surgery, saline nasal irrigation, intranasal decongestant therapy, intranasal steroids, and oral antibiotics. Clinical ranking without regard to side effects and cost suggests that endoscopic sinus surgery and antral irrigation have the highest probability of substantial symptom improvement. Other issues discussed include identification and management of gastroesophageal reflux disease (GERD), allergy, and immune deficiency.