Commentary addressing concerns raised by Dr. Slovarp and her colleagues

The commentary by Dr. Laurie Slovarp and her colleagues1 about our previous publication2 finds fault with our terminology, our clinical diagnosis criteria, and the treatment of habit cough in children. Dr. Slovarp refers to the disorder as "Pediatric Nonspecific Cough." While we will address the concerns expressed by Dr. Slovarp, our purpose in that commentary was to place the interesting data of Dr. Fujiki and colleagues into perspective.3 Dr. Fujiki and colleagues retrospectively examined children with no identified cause for chronic cough at an otolaryngology clinic between 2010 and 2022. The unique contribution of the publication was the comorbid behavioral health diagnoses of the children. Behavioral cough suppression by Dr. Fujiki reported reduced symptoms with half of the 151 children in the study requiring multiple sessions. In considering the benefit provided by Dr. Fukiki,3 it is important to be aware of the previous 58-year history of successful identification and cure of habit cough. In 1966, an astute allergist described six children seen in his practice over a 5-year period with chronic cough inconsistent with known organic causes of cough. That physician, Dr. Bernard Berman, stopped the incessant chronic coughing of those six children by what he called, "the art of suggestion."4 Dr. Berman found that the children then remained free of cough during an extended follow-up indicating that they were cured. Dr. Berman further related that he carefully considered the terminology used in some previous case reports.5, 6 He considered a psychogenic cause but saw no evidence of psychopathology for any of the six children. He further considered that the cough was a tic disorder, but he saw no suggestion of tics, only cough, in the children. He concluded that "because all children responded so quickly to a simple modality of therapy, the term habit cough seemed to be the most appropriate to describe their condition." In 1991, Dr. Weinberger and his colleagues published the identification, treatment, and outcome of nine children with habit cough and arrived at the same conclusion, "the classical habit cough syndrome is amenable to immediate relief and long-term cure for most children with a single session of appropriate suggestion therapy."7 Suggestion therapy has been the standard of care at the University of Iowa Pediatric Allergy and Pulmonary clinic since the clinic's inception by Dr. Weinberger in 1975. In 2014, the electronic record was utilized to identify 140 patients at that clinic from 1995 to 2014 with the diagnosis of habit cough based on the clinical presentation.8 Normal spirometry and sometimes a chest x-ray was sufficient to eliminate the likelihood of a pulmonary disease. A colleague and coauthor of a comprehensive review of habit cough, Dr. Ran Anbar,9 also indicated during his tenure at SUNY Upstate Medical University that he similarly diagnosed habit cough by the unique clinical presentation. Dr. Anbar's coauthor at Rainbow Children's Hospital in Cleveland also reported diagnosis of habit cough by clinical criteria.10 A publication from Brompton Hospital in London also diagnosed habit cough in the same manner, without extensive tests and medication trials to eliminate all other causes of cough.11 In fact, parents often recognize even before the diagnosis is made that their child's cough was not like any other cough in that it was repetitive, dry, present during all waking hours, but absent once asleep. Parents frequently stated that their child initially had a cold with a cough, but then the cough changed, becoming the repetitive dry cough that, no matter how frequent and severe during the day, was absent once asleep. This had been described in an adult over 300 years ago12 and continues to be characteristic of habit cough in adults.13 Absent once asleep, despite repetitive daily presence of cough, has become a sine quo non for the diagnosis. Habit cough is generally distinct from other known causes of cough, and the unique characteristics of habit cough have been recognized in medical texts from previous eras.12, 14, 15 An expansion of suggestion therapy for habit cough began following a phone call to Dr. Weinberger on February 5, 2019 from Dennis Buettner, a desperate father. His 12-year-old daughter, Bethany, was having a chronic cough consistent with habit cough for 3 months. The incessant coughing prevented all normal activities including school and socializing. Activities of parents and siblings were also disrupted by the daily coughing that stopped only when she slept. Suggestion therapy by Dr. Weinberger via teleconference provided sustained cessation of cough. Dennis placed the recording of that session on YouTube.* Following the placement of that video on YouTube, emails arrived from all over the United States and many other countries from parents who recognized a similarity of their child's cough to that of Bethany's cough on the video. Many emails were requests for help, but over 100 parents and many adults16 reported to us that they had seen the video, related the similarity of their cough to that on the video, and stopped coughing.17 They reported that the incessant coughing was stopped from viewing the video. We called this suggestion therapy by proxy.18 A map in our previous publications shows the location of parents and adults who benefited in this manner. The above narrative provides a scenario outlining the identification and treatment of habit cough over the past 58 years. Dr. Slovarp and her colleagues admonished us for not being in accordance with guidelines, most recently updated 4 years ago by a Chest Guideline and Expert Panel report.19 A published letter has already addressed the limitations of that published Guideline.20 That letter included provision of evidence to the Expert Panel stating that habit cough "is described in seven published observational studies that cover a 52-year period from 1966 to 2018. In all seven publications, the observations were of children with chronic repetitive dry daily cough that was absent once the child was asleep." The Chest Guideline committee provided neither data nor clinical experience to support their proposed change in established terminology. The chest committee errored by not recognizing the opinions and clinical experience of the two pediatricians on the committee. One of the pediatricians was dismissed because the committee chair objected to the independent sharing of information about habit cough with other committee members. The other pediatrician then resigned from the committee in protest. An example of the Chest committee's attestations that was harmful to patients was the guideline's statement that diagnostic and therapeutic trials be performed to exclude all other causes of cough before considering the possibility of a habit cough.19 As described above, that recommendation is generally superfluous since the clinical presentation is sufficiently distinct. Moreover, when that recommendation is followed, the duration of the cough is prolonged, and the multiple ineffective medication trials iatrogenically increase morbidity. Another major factitious inclusion of the Expert Panel was, "that school phobia and fear of rejection were common precipitating or perpetuating factors for the cough."19 Their reference for that statement did not describe children in school. The mean age of children with habit cough was 10 years in Iowa,8 London,11 and the archives of the Mayo Clinic (Rochester, MN).21, 22 Their reference was a study of 32 young adults with chronic cough, 20 of them had a psychiatric disorder; no children were in the reference.23 Furthermore, our clinical experience in over 300 children with habit cough was that most wanted to return to school as soon as possible; school phobia was rarely present. If a speech and language professional can provide cough cessation, that indeed provides a potential resource for physicians diagnosing habit cough. Pediatric pulmonologists should be able to diagnose habit cough based on clinical presentation as many already do, and many are effectively treating habit cough in their practice with suggestion therapy.24 Authoritative committee decisions have the potential to provide helpful information for the diagnosis and care of specific medical problems. However, committee members need to be aware of the experience and accumulated data of others, on or off the committee. Controversies may be more enlightening than a majority decision used for guidelines. When a minority of committee members disagree with the majority, based on their own experience, that minority opinion must be recognized because the issues addressed as guidelines may be controversial. Addressing those controversies may stimulate further investigation. I want to end this discussion by emphasizing that the morbidity, cost, and impact of habit cough deserves a rapid diagnosis and early treatment to allay the suffering of patient and family caused by the prolonged and often disabling coughing. While we have provided the data and experience that is the basis for current diagnosis and treatment, there is more we need to learn. There appear to be phenotypes of habit cough based on our observation of resistance to suggestion therapy in a small number of children.9, 25 They tend to have unusually rapid cough, often with every breath. Some have responded to hypnosis as described in our comprehensive review of habit cough.9 A coauthor of that review included a pediatric pulmonologist who was an experienced hypnotherapist.26 He indicated that only about half of those referred to him because of unresponsiveness to suggestion therapy responded to his efforts. There is more to learn. Meanwhile, it is the joint responsibility of pulmonologists, speech and language specialists, and others who encounter patients with unexplained involuntary chronic cough to diagnose habit cough early and treat with the measures that are demonstrably effective. Miles Weinberger: Conceptualization; writing—original draft; project administration; supervision; writing—review and editing; methodology; validation; resources; investigation; data curation. Dennis Buettner: Investigation; validation; resources; writing—review and editing; software. The authors declare no conflict of interest. Publications are available at Dr. Weinberger's website http://www.milesweinberger.com. An uberfan website http://www.habitcough.com created and maintained by Dennis and Bethany Buettner contains a documentary and interviews of adults who have benefited from proxy suggestion therapy.