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\begin{document}

\title{Misconceptions on Behavioral Cough Suppression Therapy for Pediatric
Nonspecific Cough: A Response to Weinberger and Buettner's Commentary on
Fujiki et al.}



\author[1]{Laurie Slovarp}%
\author[2]{Marie Jette}%
\author[1]{Jane Reynolds}%
\author[3]{Amanda Gillespie}%
\author[4]{Julie Barkmeier-Kraemer}%
\author[5]{Mary Sandage}%
\author[6]{Jacky Smith}%
\author[6]{Jemma Haines}%
\author[7]{Anne Vertigan}%
\author[8]{Stuart Mazzone}%
\affil[1]{University of Montana School of Speech Language Hearing and Occupational Sciences}%
\affil[2]{University of Colorado Anschutz Medical Campus Department of Otolaryngology - Head \& Neck Surgery}%
\affil[3]{Emory University}%
\affil[4]{University of Utah}%
\affil[5]{Auburn University}%
\affil[6]{The University of Manchester Faculty of Biology Medicine and Health}%
\affil[7]{The University of Newcastle School of Medicine and Public Health}%
\affil[8]{The University of Melbourne Department of Anatomy and Physiology}%


\vspace{-1em}



  
  \date{June 15, 2024}


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\textbf{Misconceptions on Behavioral Cough Suppression Therapy for
Pediatric Nonspecific Cough: A Response to Weinberger and Buettner's
Commentary on Fujiki et al.}

Laurie Slovarp, PhD, School of Speech, Language, Hearing, \&
Occupational Sciences, University of Montana

Marie Jette, PhD, Department of Otolaryngology -- Head and Neck Surgery,
University of Colorado Anschutz Medical Campus

Jane Reynolds, PhD, School of Speech, Language, Hearing, \& Occupational
Sciences, University of Montana

Amanda Gillespie, PhD, Department of Otolaryngology and Head and Neck
Surgery, Emory University

Julie Barkmeier-Kraemer, PhD, Division of Otolaryngology -- Head and
Neck Surgery, University of Utah

Mary Sandage, PhD, Speech, Language, and Hearing Sciences, Auburn
University

Jaclyn Smith, PhD, Biology, Medical and Health Sciences, The University
of Manchester

Jemma Haines, BSc(Hons), Medical and Health Sciences, The University of
Manchester, Manchester University NHS Foundation Trust

Anne Vertigan, PhD, School of Medicine and Public Health, University of
Newcastle

Stuart Mazzone, PhD, Department of Anatomy and Physiology, University of
Melbourne

\textbf{Corresponding author:} Laurie Slovarp, PhD,

School of Speech, Language, Hearing, \& Occupational Sciences,
University of Montana, Missoula, MT, 59812. Laurie.slovarp@umontana.edu
(p) 406-243-2107 (f) 406-243-2362 Orcid ID: 0000-0002-3547-4092

\textbf{Key words} : pediatric chronic cough, habit cough, suggestion
therapy, speech-language pathology

\textbf{Funding} : none

\textbf{Conflicts of Interest:} The authors declare no conflicts of
interest.

\textbf{Author Contributions} :

Laurie Slovarp: conceptualization, writing original draft, review and
editing

Marie Jette: conceptualization, writing original draft, review and
editing

Jane Reynolds: conceptualization, writing original draft, review and
editing

Amanda Gillespie: conceptualization, writing original draft, review and
editing

Julie Barkmeier-Kraemer: review and editing

Mary Sandage: review and editing

Jaclyn Smith: review and editing

Jemma Haines: review and editing

Anne Vertigan: review and editing

Stuart Mazzone: writing, review, and editing

\textbf{Abstract/Summary} : This commentary responds to Weinberger and
Buettner's critique of Fujiki et al.'s study on behavioral cough
suppression therapy (BCST) for pediatric chronic cough. While
acknowledging their contributions, it addresses inaccuracies and
clarifies key aspects of BCST. The commentary highlights discrepancies
in terminology, challenges assertions regarding diagnostic evaluations,
and emphasizes the need for controlled trials to assess treatment
efficacy.

In their engagement with the study by Fujiki et al.\textsuperscript{1},
Weinberger and Buettner\textsuperscript{2} bring attention to critical
aspects of behavioral cough suppression therapy (BCST) and pediatric
chronic cough treatment. While their contributions are valued, it is
imperative to address certain inaccuracies and clarify key aspects of
the study and BCST provided by specialized speech-language pathologists
(SLPs).

Firstly, Weinberger \& Buettner inaccurately state that Fujiki et al.
identified the children as having ''behavioral cough.'' The term
''behavioral cough'' in the paper was used only in the context of
''\emph{behavioral cough} suppression therapy,'' describing the
treatment rather than the children's cough diagnosis. The authors, in
fact, used the term ''nonspecific cough/tic cough'' in accordance with
current CHEST and ERS guidelines\textsuperscript{3-5}. Weinberger \&
Buettner's assertion that ''historical evidence and current practice
support ``habit cough'' as the appropriate diagnosis'' lacks
substantiation and contradicts contemporary CHEST
guidelines\textsuperscript{5}. We are particularly puzzled by Weinberger
\& Buettner's advocacy for the term habit cough when Dr. Weinberger is
listed as an author on a 2015 CHEST guidelines publication that
explicitly advises against the use of these terms, deeming them ''out of
date and inaccurate''\textsuperscript{5}.

Weinberger \& Buettner also criticize the use of extensive evaluations
for the children in the sample, arguing that ``habit cough'' can be
diagnosed based on clinical presentation alone---specifically in the
presence of a barking or honking cough and absence of the cough during
sleep. Interestingly, the same CHEST guidelines, of which Weinberger is
an author, specifically cautions against using the diagnostic terms of
``psychogenic'' or ``habit cough'' solely based on a barking or honking
sound or the absence of cough during sleep, stating that these three
clinical presentations lack specificity\textsuperscript{5}. A barking or
honking cough can occur with other diseases such as tracheomalacia or
bronchiectasis\textsuperscript{6}; and it is well documented that sleep
inhibits the cough reflex in adults even when an organic disease process
is identified\textsuperscript{7; 8}. Without evidence to the contrary,
it is should be assumed that sleep similarly suppresses cough in
children. Further, the purpose of Fujiki et al.'s paper was to examine
whether BCST improves cough in children and to describe cough
characteristics and comorbidities, not to advocate for extensive
assessments. Although, it is noteworthy that laryngoscopy revealed
structural laryngeal pathology in several cases, challenging Weinberger
\& Buettner's assertion that the described assessments were unjustified.

Regarding the treatment described in Fujiki et al., Weinberger \&
Buettner characterize BCST as an ``alternative to suggestion therapy.''
This overlooks that BCST instructs in strategies to suppress cough, akin
to his ``suggestion therapy.'' Therefore, it seems that BCST is not
necessarily an alternative but rather a similar therapy with a different
name. This overlap emphasizes the need for clarity in terminology.
Importantly, in adults with chronic cough a loss of centrally (brain)
mediated cough suppression has been demonstrated using functional brain
imaging\textsuperscript{9}.~ Although empirical data in children is not
available, it seems conceivable that similar mechanisms may be in
operation, providing a neurobiological basis for why cough suppression
training is often beneficial and supporting the use of terminology that
emphasizes this aspect of the therapy.

Additionally, Weinberger \& Buettner's argument that 45 pediatric
pulmonologists ''already indicate they readily diagnose habit cough and
successfully treat with suggestion therapy,'' implies a stance against
SLP treatment. However, considering there are thousands of pediatric
pulmonologists in the U.S. alone, the sample size of 45 falls short of
substantiating the claim that ''many'' pulmonologists universally adopt
this approach or that additional clinicians, such as SLPs, are
unnecessary to assist these patients effectively. The argument lacks
robust evidence and fails to account for the role of additional
clinicians, such as SLPs, to address pediatric chronic cough
effectively. Further, a substantial proportion of children in Fujiki et
al.'s sample presented with phonotraumatic lesions (e.g., vocal
nodules), which SLPs are specifically trained to address through
behavioral treatment.

Lastly, Weinberger \& Buettner suggest that conducting a controlled
trial for suggestion therapy is impractical due to the reported low
frequency of referrals. We disagree that the size of the population is a
valid argument for not conducting a randomized controlled trial. A
control group is needed to robustly assess the efficacy of any
treatment, particularly in the case of cough interventions which are
particularly vulnerable to placebo effect\textsuperscript{10; 11}.
Weinberger \& Buettner suggest that it would be unethical to withhold
suggestion therapy for the sake of a randomized clinical trial; however,
one could easily design a study that allowed for those randomized to a
control treatment to be eligible for suggestion therapy upon completion
of the control arm. Given Dr. Weinberger's data suggests suggestion
therapy eliminates nonspecific/tic cough in less than one week, such
children would need to wait no more than one to two weeks before
becoming eligible for suggestion therapy and it should be possible to
demonstrate such a substantial effect in a relatively small number of
subjects in a randomized controlled trial.

We agree with Dr. Weinberger that SLP skills vary. As is the case with
any clinical discipline, there are many subspecialties in the field of
speech-language pathology and varying levels of skill and expertise
within those subspecialties. BCST training is not standard in SLP
training programs, and, therefore, requires special training.

In conclusion, we think these clarifications underscore the importance
of understanding Fujiki et al.'s paper in its correct context, and will
advance a more nuanced and informed discussion on pediatric cough
disorders and BCST's role in treatment. We acknowledge Weinberger \&
Buettner's contribution to pediatric cough management. The data reported
in this letter and other publications\textsuperscript{12; 13}, although
anecdotal, suggests that behavioral treatment focused on cough
suppression is effective. Given this, we encourage Weinberger and
Buettner to complete a randomized controlled efficacy trial. If the data
confirms efficacy, the study would significantly elevate the legitimacy
of the treatment, increasing its use by other practitioners and
benefitting pediatric patients with chronic cough.

REFERENCES

1. Fujiki RB, Wright ML, Fujiki AE, Thibeault SL. 2023. Factors
influencing behavioral cough suppression therapy in children with
nonspecific chronic cough. Pediatr Pulmonol. 58(12):3466-3477.

2. Weinberger M, Buettner D. 2024. The habit cough syndrome. Pediatr
Pulmonol. 59(2):260-262.

3. Chang AB, Oppenheimer JJ, Irwin RS, Panel CEC. 2020. Managing chronic
cough as a symptom in children and management algorithms: CHEST
guideline and expert panel report. Chest. 158(1):303-329.

4. Morice AH, Millqvist E, Bieksiene K, Birring SS, Dicpinigaitis P,
Domingo Ribas C, Hilton Boon M, Kantar A, Lai K, McGarvey L et al. 2020.
ERS guidelines on the diagnosis and treatment of chronic cough in adults
and children. Eur Respir J. 55(1).

5. Vertigan AE, Murad MH, Pringsheim T, Feinstein A, Chang AB, Newcombe
PA, Rubin BK, McGarvey LP, Weir K, Altman KW et al. 2015. Somatic cough
syndrome (previously referred to as psychogenic cough) and tic cough
(previously referred to as habit cough) in adults and children: CHEST
guideline and expert panel report. Chest. 148(1):24-31.

6. Spinou A, Lee KK, Sinha A, Elston C, Loebinger MR, Wilson R, Chung
KF, Yousaf N, Pavord ID, Matos S et al. 2017. The objective assessment
of cough frequency in bronchiectasis. Lung. 195(5):575-585.

7. Lee KK, Birring SS. 2010. Cough and sleep. Lung. 188 Suppl 1:S91-94.

8. Power JT, Stewart IC, Connaughton JJ, Brash HM, Shapiro CM, Flenley
DC, Douglas NJ. 1984. Nocturnal cough in patients with chronic
bronchitis and emphysema. Am Rev Respir Dis. 130(6):999-1001.

9. Ando A, Smallwood D, McMahon M, Irving L, Mazzone SB, Farrell MJ.
2016. Neural correlates of cough hypersensitivity in humans: Evidence
for central sensitisation and dysfunctional inhibitory control. Thorax.
71(4):323-329.

10. Eccles R. 2009. Central mechanisms iv: Conscious control of cough
and the placebo effect. Handb Exp Pharmacol. (187):241-262.

11. Eccles R. 2010. Importance of placebo effect in cough clinical
trials. Lung. 188 Suppl 1:S53-61.

12. Lokshin B, Lindgren S, Weinberger M, Koviach J. 1991. Outcome of
habit cough in children treated with a brief session of suggestion
therapy. Ann Allergy. 67(6):579-582.

13. Weinberger M, Hoegger M. 2016. The cough without a cause: Habit
cough syndrome. J Allergy Clin Immunol. 137(3):930-931.

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