Rebecca Dingle's daughter Lily first developed a cough when she was two and a half years old.
But it was not until she was almost four that she finally got a diagnosis.
"We took her to the doctor after she had the cough for 12 weeks," Ms Dingle says.
"They listened to her chest, they looked in her ears … [and] throat. They said it's just a virus."
A year later, Lily was worse.
"She was coughing all the time," Ms Dingle says.
"And particularly at night-time, she would cough until she vomited."
It would take her another eight years and multiple hospital stays of up to four weeks to start to recover.
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When is a cough considered chronic?
The job of a cough is to help maintain respiratory health, says Julie Marchant, a respiratory physician and researcher at Queensland Children's Hospital.
"It helps clear the airway in both healthy people and those with lung disease," Dr Marchant says.
"And [it] can be voluntary or involuntary."
Not all coughs are of a concern, she says
For example, children are often prone to viral infections, which can cause a cough. However, she says, those usually clear up on their own.
"The question I always ask parents is, when do they last remember a day when their child didn't cough?" she says.
But chronic coughs that last more than four weeks in children should be investigated as it could point towards other underlying problems, says Dr Marchant, the lead author of new guidelines for doctors about how to identify and manage chronic coughs.
"If [children] are coughing every single day without breaks in between infections, then they probably have a chronic cough," Dr Marchant says.
Any cough that has lingered for more than two months in adults is "not normal" and should be investigated, says Peter Wark, a specialist in respiratory and sleep medicine at the Alfred Hospital in Melbourne.
"Chronic cough should not be ignored," says Professor Wark, who was also involved in writing the guidelines.
"It may represent a serious underlying condition and in most cases it can be effectively treated."
Beware of wet coughs in kids
Dr Marchant says it is important to identify whether a child's cough is wet or dry.
"I recommend [parents] record their child's cough [on a smartphone or other recording device] before they go and see the doctor," she says.
"Because sometimes, particularly in preschool children, it's difficult to ask them to cough on command."
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She says the most common cause of a wet chronic cough in children is protracted bacterial bronchitis.
This condition, which involves inflammation of the large airways, is treated with a prolonged course of antibiotics.
But it can be tricky to diagnose, says Kerry Hancock, chair of The Royal Australian College of General Practitioners Respiratory Medicine Special Interest Group.
"In the early stages, it's very hard to differentiate between a viral infection [which doesn't respond to antibiotics] and a bacterial infection [which requires antibiotics]," says Dr Hancock, who was not a member of the guideline group.
"And protracted bacterial bronchitis often does follow on from a viral infection."
Dr Hancock says this raises clinical challenges because "it's always been emphasised to doctors to not give antibiotics unnecessarily".
Another serious source of a chronic wet cough that can be overlooked is choking, Dr Marchant says.
"The child could have a foreign body in their airway … and the parents haven't realised," she says.
What to look out for in adults
A chronic cough may occur in up to 10 per cent of adults in their lifetime, Professor Wark says.
He says it is more common in people who smoke and vape and sometimes can be triggered by exposures at work.
It can also be a sign of serious underlying diseases such as chest or lung disease, including lung cancer, that needs investigation.
Smoking increases the risk of the cough being a sign of one of these serious diseases.
Professor Wark says a cough that is dry (no mucus) is common and may indicate underlying lung disease, especially when associated with shortness of breath.
Chronic coughs associated with sputum or phlegm in adults can be an indication of underlying conditions such as chronic bronchitis and asthma and need treatments to prevent lung damage.
Not all chronic coughs in adults point to serious conditions. They can also occur as a result of more benign, but annoying, conditions such as diseases that affect the sinuses and the nose, including allergic rhinitis causing sneezing and an itchy nose, and chronic sinusitis where the sinuses — the space inside the nose and the head — become inflamed and swollen.
They can also be associated with reflux or heartburn, but if this is the case, there are usually other symptoms, such as a burning sensation in your chest.
Some people have what's called a chronic refractory cough, a cough that resists treatment.
John Hunter Hospital director of speech pathology Anne Vertigan says about 20 to 40 per cent of people with a chronic cough, who have no underlying health issues, will not respond to medical treatment.
"People with a chronic cough often … also have problems breathing, and they have problems with the voice as well," Dr Vertigan says.
She says people with this condition can be taught to identify and reduce irritation and given exercises to suppress or delay coughs.
Getting an early diagnosis is key
Patients and parents should not be afraid to ask their GP to do further investigations if symptoms do not improve, says Dr Hancock, who welcomes the new guidelines.
"[Diagnosing chronic cough] … requires taking a really good history and doing the examination, plus those initial investigations of chest X-ray and lung function testing," she says.
"Often [patients] can be have a cough for many, many months before somebody actually takes it seriously. And conditions … can be missed because they are not investigated early enough or appropriately."
Dr Marchant says if a child is not getting better after four weeks, then a parent should seek a referral to a respiratory doctor.
"There is significant evidence now that if you leave, particularly, a wet cough in children untreated, it increases their risk of developing a chronic infection in their chest," Dr Marchant says.
Ongoing chest infections increases the risk of a condition known as bronchiectasis, where the airways become damaged causing them to widen.
"So the big thing for children is early intervention and if there is any damage there, we usually can reverse it, provided that they get an appropriate treatment."
Lily’s recovery
For Lily, the road to a diagnosis was long and painful.
When an initial dose of oral antibiotics did not help, her paediatrician decided to do a bronchoscopy, an examination of the windpipe and airways via a flexible telescope.
It showed her lungs were filled with pus, so she was admitted to hospital and given intravenous antibiotics.
Altogether, it took Rebecca Dingle 16 months to find out Lily was suffering from bronchiectasis.
"I felt relieved that I wasn't crazy, that I hadn't wasted all these people's time. I felt relieved that I'd fought so hard for [my daughter]," says Ms Dingle, who contributed to the guidelines.
"We were so relieved that we had an answer. And so relieved that we had a treatment."
In the first four years after diagnosis, Lily needed prophylactic antibiotics for four weeks at a time, about every nine months, to prevent infection.
Now eleven and a half years old, this is the first year that her health has improved long enough to stop taking them.
Ms Dingle, who is an occupational physician, says the whole process has been difficult.
As a volunteer for the Lung Foundation Australia, Ms Dingle has helped put together some information for parents including questions to ask your doctor.
"There's hope, and there's a way forward and there are resources to help you," Ms Dingle says.
"And you don't have to do it by yourself."
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