*This post originally appeared on The PediaBlog on February 15, 2013:

 

The Persistent Cough

 

An important study published in the Annals of Family Medicine attempts to answer this question:  “How long does a cough last?” Sally Kalson gives it to us straight:

If your cough is hanging on much longer than you expected, the problem isn’t the cough; it’s you.

People expect acute coughing from a cold or flu to last seven to nine days, according to a new report, when it actually takes closer to 18 days to run its course.

The perception gap leads to more doctor visits, more pointless use of antibiotics (which don’t work on viruses, the cause of most coughs), higher medical bills and more drug resistance.

 

Investigators at the University of Georgia recognized how commonly people seek medical care for coughs, especially those that linger beyond what is expected:

Acute cough illness (ACI) is one of the most common reasons that patients seek care in the outpatient primary care setting. In 2006 there were more than 3 million outpatient visits in the United States for a chief complaint of cough and more than 4.5 million outpatient visits with a final diagnosis of “acute bronchitis or bronchiolitis.” Overall, ACI accounts for approximately 2% to 3% of visits to outpatient physicians.

Although typically a self-limited condition caused by viruses, many patients seek care and request antibiotics for ACI. Even though the rate of antibiotic prescribing for ACI is decreasing (from 65% of visits for ACI in 1996 to 50% in 2006), it remains too high.

 

According to the study, people feel that a cough should last no longer than 7 or 8 days before it naturally resolves. In reality, most cough illnesses last 17-18 days before they’re gone! Here’s the key why this is important to both you and your doctor:

The mismatch between patients’ expectations and reality for the natural history of acute cough illness has important implications for antibiotic prescribing. If a patient expects that an episode of ACI should last about 6 or 7 days, it makes sense that they might seek care for that episode and request an antibiotic after 5 or 6 days. Furthermore, if they begin taking an antibiotic 7 days after the onset of symptoms, they may begin to feel better 3 or 4 days later, with the episode fully resolving 10 days later. Although this outcome may reinforce the mistaken idea that the antibiotic worked, it is merely a reflection of the natural history of ACI.

 

While this study should be read by primary care and emergency room doctors everywhere, it becomes a little more complicated with pediatric patients. First of all, there aren’t that many parents who actually demand antibiotics for their children, even if they understandably expect them. Antibiotics can be a royal pain to give to children. Some taste nasty (for many kids, any medicine tastes nasty), some have to be given more than once a day, all can cause severe side effects (especially diarrhea and rashes). They can be very expensive, without any guarantee that they will work. Most parents I encounter are relieved when I tell them their child’s illness will most likely resolve without the use of any prescribed or over-the-counter medications.

For most children, it’s not just the cough or the runny nose that triggers an office visit. It’s the coughing at night where the child (and parent) can’t sleep. It’s the crusty and gooey nose that needs to be constantly wiped. It’s the fever that makes kids cranky and leaves their beds unslept in, their meals uneaten, and their parents unhappy with worry.

For the pediatrician, it’s all about the “what ifs.” What if I say no to antibiotics today and the child comes back next week and is worse? (A typical story for ear and sinus infections, and pneumonia, actually.) What if the fluid in the untreated ear turns into a raging ear infection? (Major pain and screaming at 2 am.) What if this cough that has lasted a day, or a week, or two weeks, or more, represents pneumonia? Do I really want to X-ray an otherwise well child for an otherwise benign-sounding, though prolonged, cough? (Trip to the hospital, irradiation, more expense.)

What if I’m wrong? The burden is on doctors — not parents — to clearly describe what we are seeing and thinking regarding the patient before us. If I recommend a specific treatment, I’d better have a good reason why and be prepared to explain. Ditto if I decide that letting things ride without specific treatment is the better option. Either way, I’ve got to get parents to understand and agree (and feel confident) with the plan. If I can’t get parents to formulate a plan with me, then the blame almost always resides with one person: Me.