{'fraction_non_alphanumeric': 0.023566084788029924, 'fraction_numerical': 0.0059850374064837905, 'mean_word_length': 5.310778914240755, 'pattern_counts': {'":': 0, '<': 0, '<?xml version=': 0, '>': 1, 'https://': 0, 'lorem ipsum': 0, 'www.': 0, 'xml': 0}, 'pii_count': 0, 'substrings_counts': 0, 'word_list_counts': {'cursed_substrings.json': 0, 'profanity_word_list.json': 0, 'sexual_word_list.json': 0, 'zh_pornsignals.json': 0}}
A multi‐disciplinary approach to chronic cough in children

Abstract Objectives (1) To highlight the important causes of chronic and recurrent cough in children. (2) To discuss multidisciplinary approach to management of chronic/recurrent pediatric cough. Methods Review of scholarly articles, guidelines, expert panels via PubMed and Google Scholar. Conclusion Chronic cough (CC) in children is mainly attributed to persistent bacterial bronchitis, asthma, nonspecific cough, and gastroesophageal reflux disease (GERD) symptoms. A multi‐disciplinary approach is cost‐effective and aids with earlier diagnosis and appropriate treatment. Congenital or acquired narrowing of the subglottis is the leading ENT cause for recurrent croup (RC) in children. Laryngeal cleft‐type 1 is commonly seen in children with recurrent aspiration and CC. Children are usually referred to pulmonologists for wet cough not responding to treatment. Eosinophilic esophagitis (EoE) and GERD should be considered in the differential diagnosis of CC in children with both respiratory symptoms and failure to thrive. Level of Evidence: 2a

and chest wall musculature as well as age related maturations of the respiratory center and respiratory control of the cough reflex. [10][11][12] Cough sensitivity in children is influenced by airway caliber and age. 13 The leading causes for CC in children are persistent bacterial bronchitis (PBB), Asthma and gastroesophageal reflux disease (GERD). Table 1 shows the most common causes of CC in children.
The American College of Chest Physicians have proposed guidelines and an algorithm 1 to assist clinicians in the management of pediatric CC. Figure 1 outlines a modified algorithm applicable to otolaryngology practices. The evaluation of a child with CC should include a detailed history, physical examination, and testing when appropriate.
Patients are divided into patients with a characteristic cough, with specific cough pointers, and without specific cough pointers. Cough pointers essentially signify an identifiable cause or more severe illness. 9,14 Cough is considered "specific" when specific cough pointer symptoms and signs are present, and the etiology can be attributed to an underlying abnormality or disease. Cough pointers ( Table 2) include nature of the cough (wet or dry), classically recognizable cough sounds (barky croup cough), auscultatory findings such as wheeze, and associated conditions such as digital clubbing, failure to thrive (FTT), feeding difficulties, recurrent pneumonia and abnormalities on chest radiograph or spirometry. Environmental factors such as tobacco smoke exposure, indoor and outdoor allergen exposure should also be evaluated.

| ROLE OF THE OTOLARYNGOLOGIST IN MANAGEMENT OF CC
Conditions that cause CC seen by a pediatric otolaryngologist differ from those seen by the pediatrician. 15 Otolaryngologists play a unique role in the multidisciplinary management of CC in children by aiding earlier identification of those cases of CC that require diagnostic work up and surgical intervention. They are also an integral part of an Aerodigestive Program. The role of the otolaryngologist in diagnosis and management of specific causes of CC are discussed below (after section on triple endoscopy).

| ROLE OF THE PULMONOLOGIST IN MANAGEMENT OF CC
As mentioned earlier the common causes of CC in children are asthma, PBB, GERD, and nonspecific cough. Many of these can be initially managed by a non-pulmonologist. However, if there is failure for the cough to resolve, recurrence, or concern for an underlying disease due to specific cough pointers, referral to a pulmonologist is recommended where they can undergo further evaluation and testing.
Radiography (x-ray or CT), pulmonary function testing, and flexible bronchoscopy (FB) with broncho-alveolar lavage are diagnostic tests that can be coordinated with a pulmonologist, as needed.

| ROLE OF GASTROENTEROLOGIST IN MANAGEMENT OF CC
GERD has been postulated as a cause for CC in children, although it appears to be less commonly identified as the etiology in comparison to adults with CC. 16 The mechanism for GERD-induced cough is not completely clear but is generally hypothesized to be related to microaspiration of refluxed gastric contents into the proximal airway versus a neuronal esophagobronchial reflex triggered by distal esophageal reflux and mediated via the vagus nerve. 5 Furthermore, proving a cause and effect relationship between GERD and CC is difficult, due in part to the lack of a gold standard diagnostic test for GERD in infants and children. 17 Thus given the tenuous relationship between GERD and CC, it is not recommended to use GERD treatments for CC in the absence of other clinical features of GERD, such as recurrent regurgitation, heartburn or chest/ epigastric pain. 7,17 If the diagnosis of GERD is not clear, objective testing such as esophagogastroduodenoscopy (EGD) with biopsies or combined esophageal multichannel intraluminal impedance with pH monitoring (pH-MII) may be considered. Endoscopy may reveal evidence of reflux esophagitis or other conditions such as eosinophilic esophagitis (EoE), while pH-MII monitoring may be especially helpful for assessing the temporal correlation between cough and reflux events. When signs and symptoms or tests consistent with pathological gastroesophageal reflux are present, treatments such as thickened feeds in infants or pharmacological acid suppression with protonpump inhibitors (PPIs) or H 2 receptor antagonists in older children may be considered on a short-term trial basis. 17 Indeed, the potential for efficacy in treating CC should be balanced with the emerging concern for possible adverse events related to long-term PPI use, such as increased risk of infections and bone fractures. 18 (Table 3). Both studies underscore the importance of comprehensive inter-disciplinary management of children with CC and or concurrent other symptoms such as feeding/ weight problems. Triple endoscopy in these children not only leads to correct diagnosis with excellent outcome after targeted treatment but also reduces costs and risks associated with repeated anesthesia.

| Recurrent croup
Croup is said to be recurrent when a child has 2-3 or more episodes of croup like symptoms within a single season. 23

| Important non-ENT causes of CC with feeding/weight issues: EoE
EoE should also be considered in children who present with poor feeding in the context of respiratory symptoms such as CC. EoE is a chronic inflammatory condition of the esophagus characterized by symptoms related to esophageal dysfunction and eosinophilic inflammation, which is typically defined as >15 eosinophils per high powered field of the esophageal mucosa. 44 Younger patients tend to present with more nonspecific symptoms, including feeding difficulties, dysphagia to liquids and/or solids, vomiting, regurgitation, and poor weight gain, while older adolescents and adults present with dysphagia to solids and food impactions. 45

| Asthma
Asthma is a common chronic disorder of the airways that is complex and characterized by variable and recurring symptoms, airflow obstruction, bronchial hyperresponsiveness, and an underlying inflammation. 51 Cough is a frequent symptom in patients with asthma, particularly persistent nocturnal cough. Cough that is associated with asthma is typically dry, but a wet cough does not exclude asthma.

| CONCLUSION
CC in children is mainly attributed to PBB, asthma, nonspecific cough, and GERD symptoms. A multi-disciplinary approach is cost-effective and aids with earlier diagnosis and appropriate treatment. Congenital or acquired narrowing of the subglottis is the leading ENT cause for RC in children. LC1 is commonly seen in children with recurrent aspiration and CC. Children are usually referred to pulmonologists for wet cough not responding to treatment. EoE and GERD should be considered in the differential diagnosis of CC in children with both respiratory symptoms and FTT.