Approach to chronic cough in children
- Roni Grad, MD
Roni Grad, MD
- Associate Professor of Clinical Pediatrics
- University of Arizona College of Medicine
Coughing is an important defensive reflex that protects from aspiration of foreign materials, and enhances clearance of secretions and particulates from the airways. Healthy children may cough on a daily basis; one study documented an average of 11 cough episodes every 24 hours . However, a cough may also be the presenting symptom of a serious underlying pulmonary or extrapulmonary disease. The causes of chronic cough in children are quite different from that of adults, so evaluation and management of children should not be based on adult protocols. Adolescents 15 years and older may be evaluated using guidelines for adults . (See "Evaluation of subacute and chronic cough in adults".)
The differential diagnosis of chronic cough in children includes subacute and chronic infections (eg, bacterial bronchitis, pertussis, mycoplasma, and tuberculosis), foreign body aspiration, and cough-dominant asthma (table 1) . Gastroesophageal reflux, upper airway cough syndrome (formerly known as postnasal drip syndrome), and sinusitis are sometimes implicated because of associations with chronic cough in adults, but their role in causing chronic cough in children is controversial . Warning signs warranting concern include a cough that is unusually severe and/or frequent, failure to thrive, growth retardation, purulent sputum, exertional dyspnea, hypoxemia, chest pain, or hemoptysis. (See "Causes of chronic cough in children".)
An approach to the diagnosis and management of chronic cough in children is presented here. Approaches to wheezing and stridor in children are presented separately. (See "Approach to wheezing in children" and "Wheezing illnesses other than asthma in children" and "Assessment of stridor in children".)
Epidemiologic studies of cough in children have been hampered by the variable definitions used for defining chronicity, the presence of other concomitant symptoms (eg, wheezing), the lack of widely accepted objective clinical endpoints to measure cough severity, and the tendency for cough to resolve spontaneously [4,5].
Despite these limitations, chronic cough appears to be common, with an estimated prevalence of 5 to 7 percent in preschoolers, and 12 to 15 percent in older children [6,7]. Cough is more common among boys than girls up to 11 years of age , and may be less common in developing countries than in affluent countries .
- Munyard P, Bush A. How much coughing is normal? Arch Dis Child 1996; 74:531.
- Chang AB, Glomb WB, ). Guidelines for evaluating chronic cough in pediatrics: ACCP evidence-based clinical practice guidelines. Chest 2006; 129:260S.
- de Jongste JC, Shields MD. Cough . 2: Chronic cough in children. Thorax 2003; 58:998.
- Bush A. Paediatric problems of cough. Pulm Pharmacol Ther 2002; 15:309.
- Chang AB, Asher MI. A review of cough in children. J Asthma 2001; 38:299.
- Stein RT, Holberg CJ, Sherrill D, et al. Influence of parental smoking on respiratory symptoms during the first decade of life: the Tucson Children's Respiratory Study. Am J Epidemiol 1999; 149:1030.
- Chang AB, Powell CV. Non-specific cough in children: diagnosis and treatment. Hosp Med 1998; 59:680.
- Faniran AO, Peat JK, Woolcock AJ. Measuring persistent cough in children in epidemiological studies: development of a questionnaire and assessment of prevalence in two countries. Chest 1999; 115:434.
- Chang AB, Landau LI, Van Asperen PP, et al. Cough in children: definitions and clinical evaluation. Med J Aust 2006; 184:398.
- Shields MD, Bush A, Everard ML, et al. BTS guidelines: Recommendations for the assessment and management of cough in children. Thorax 2008; 63 Suppl 3:iii1.
- Chang AB. Cough, cough receptors, and asthma in children. Pediatr Pulmonol 1999; 28:59.
- Widdicombe JG. Sensory neurophysiology of the cough reflex. J Allergy Clin Immunol 1996; 98:S84.
- Tekdemir I, Aslan A, Elhan A. A clinico-anatomic study of the auricular branch of the vagus nerve and Arnold's ear-cough reflex. Surg Radiol Anat 1998; 20:253.
- Morice AH, Geppetti P. Cough. 5: The type 1 vanilloid receptor: a sensory receptor for cough. Thorax 2004; 59:257.
- McCool FD. Global physiology and pathophysiology of cough: ACCP evidence-based clinical practice guidelines. Chest 2006; 129:48S.
- Schramm CM. Current concepts of respiratory complications of neuromuscular disease in children. Curr Opin Pediatr 2000; 12:203.
- Chang AB, Robertson CF, van Asperen PP, et al. A cough algorithm for chronic cough in children: a multicenter, randomized controlled study. Pediatrics 2013; 131:e1576.
- Marchant JM, Masters IB, Taylor SM, Chang AB. Utility of signs and symptoms of chronic cough in predicting specific cause in children. Thorax 2006; 61:694.
- Marchant JM, Masters IB, Taylor SM, et al. Evaluation and outcome of young children with chronic cough. Chest 2006; 129:1132.
- Boat TF. Pulmonary hemorrhage and hemoptysis. In: Kendig's Disorders of the Respiratory Tract in Children, 6th, Chernick V, Boat TF (Eds), WB Saunders, Philadelphia 1998. p.623.
- Chambers KJ, Setlur J, Hartnick CJ. Chiari type I malformation: presenting as chronic cough in older children. Laryngoscope 2013; 123:2888.
- Eysink PE, Bottema BJ, ter Riet G, et al. Coughing in pre-school children in general practice: when are RAST's for inhalation allergy indicated? Pediatr Allergy Immunol 2004; 15:394.
- Castro-Rodríguez JA, Holberg CJ, Wright AL, Martinez FD. A clinical index to define risk of asthma in young children with recurrent wheezing. Am J Respir Crit Care Med 2000; 162:1403.
- Austin JB, Russell G. Wheeze, cough, atopy, and indoor environment in the Scottish Highlands. Arch Dis Child 1997; 76:22.
- Robin LF, Less PS, Winget M, et al. Wood-burning stoves and lower respiratory illnesses in Navajo children. Pediatr Infect Dis J 1996; 15:859.
- Garrett MH, Hooper MA, Hooper BM, Abramson MJ. Respiratory symptoms in children and indoor exposure to nitrogen dioxide and gas stoves. Am J Respir Crit Care Med 1998; 158:891.
- Asilsoy S, Bayram E, Agin H, et al. Evaluation of chronic cough in children. Chest 2008; 134:1122.
- Rosenstreich DL, Eggleston P, Kattan M, et al. The role of cockroach allergy and exposure to cockroach allergen in causing morbidity among inner-city children with asthma. N Engl J Med 1997; 336:1356.
- Phipatanakul W, Eggleston PA, Wright EC, et al. Mouse allergen. II. The relationship of mouse allergen exposure to mouse sensitization and asthma morbidity in inner-city children with asthma. J Allergy Clin Immunol 2000; 106:1075.
- Hirsch T, Weiland SK, von Mutius E, et al. Inner city air pollution and respiratory health and atopy in children. Eur Respir J 1999; 14:669.
- Nicolai T. Air pollution and respiratory disease in children: what is the clinically relevant impact? Pediatr Pulmonol Suppl 1999; 18:9.
- Schwartz J. Air pollution and children's health. Pediatrics 2004; 113:1037.
- Smith KR, Samet JM, Romieu I, Bruce N. Indoor air pollution in developing countries and acute lower respiratory infections in children. Thorax 2000; 55:518.
- Marchant JM, Newcombe PA, Juniper EF, et al. What is the burden of chronic cough for families? Chest 2008; 134:303.
- Newcombe PA, Sheffield JK, Chang AB. Parent cough-specific quality of life: development and validation of a short form. J Allergy Clin Immunol 2013; 131:1069.
- Dye C, Scheele S, Dolin P, et al. Consensus statement. Global burden of tuberculosis: estimated incidence, prevalence, and mortality by country. WHO Global Surveillance and Monitoring Project. JAMA 1999; 282:677.
- Meza MP, Benson M, Slovis TL. Imaging of mediastinal masses in children. Radiol Clin North Am 1993; 31:583.
- Carty H. Ultrasound of the normal thymus in the infant: a simple method of resolving a clinical dilemma. Br J Radiol 1990; 63:737.
- Weinberger M. Airways reactivity in patients with CF. Clin Rev Allergy Immunol 2002; 23:77.
- Morice AH, Fontana GA, Sovijarvi AR, et al. The diagnosis and management of chronic cough. Eur Respir J 2004; 24:481.
- Shopfner CE, Rossi JO. Roentgen evaluation of the paranasal sinuses in children. Am J Roentgenol Radium Ther Nucl Med 1973; 118:176.
- Ineffective cough
- DIAGNOSTIC APPROACH
- Specific cough
- - Key symptoms and signs
- Nonspecific cough
- Age and circumstances at onset
- Nature of the cough
- Timing and triggers
- Associated symptoms
- Past medical history
- Family history
- Social history and environmental exposures
- PHYSICAL EXAMINATION
- General examination
- Chest examination
- CHEST RADIOGRAPHY
- PULMONARY FUNCTION TESTS
- OTHER TESTS
- Esophageal pH monitoring
- Sinus imaging
- Tuberculin testing
- Allergy testing
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS