Approach to chronic cough in children

Dr.D.K.Patgiri, M.D., D.C.H.

Retd. Prof. & Head of Pediatrics
Ex-Vice Principal,
Assam Medical College & Hospital, Dibrugarh.
1. Introduction:
The mammalian cough reflex is designed to protect the lower airways and
air exchanging regions of the lung from infection and inhalation of foreign
substances. Cough is due to irritation of sensory nerve endings in the
larynx, trachea and major bronchi. Normal children wearing cough meters
have been recorded as coughing 10-11 times per day, but rarely at night.
During respiratory infections or in recurrent cough, it may occur 60-100
times by day and less often at night. Coughing at night is a major concern
for parents, possibly because of the low ambient noise at night, a long
spell in close proximity to the child and the fact that coughing disturbs the
parents sleep. Chronic cough impacts a childs activity level and ability to
sleep well, play or attend school and is often a source of parental anxiety.
Cough in children is different from that of adults in terms of duration,
presentation, etiology and management.
2. Pathophysiology:
Cough is one of the most important protective reflexes and it contributes
significantly to the innate immunity of the respiratory system by
enhancing muco-cilliary clearance. Cough is under both voluntary and
involuntary control. Cough receptors are terminations of vagal afferent
nerves located in the larynx, pharynx and tracheobronchial tree. Extrapulmonary sites, such as the external ear can trigger cough due to
stimulation of the auricular branch of the vagus nerve. These receptors
send signals back to the cough centre in the medulla oblongata, which
then triggers the cough. Factors that influence cough efficiency include
adequate airway calibre, mucous properties and respiratory muscle
strength. The important consideration is that cough is a protective reflex,
it is crucial not to suppress it without identifying and treating its
underlying causes.
3. Definition:
In the British Thoracic Society (BTS) guidelines, chronic cough in children
is defined as cough lasting longer than eight weeks. This guideline is used
because most simple infective cough will resolve in 3-4 weeks and the
eight week definition identifies those who may need further investigations.
These guidelines also note that the timeframe between acute and chronic
cough (3-8 weeks) is sometimes called sub-acute cough or prolonged
acute cough.
In the other guidelines including those from American College of chest

physician and Thoracic Society of Australia and New Zealand, chronic

cough is defined as a cough lasting more than four weeks. Prevalence of
chronic cough in children has been reported as being as high as 5-10%.
Studies suggest that in 90% of children with upper respiratory tract
infection, the cough has settled within 25 days.
4.

Aetiology:

Common causes in Primary Care:

a) Recurrent infections including RSV, adenovirus, Mycoplasma pneumonia,
Chlamydial pneumonia, whooping cough and tuberculosis.
b) Asthma
c) Post-nasal drip syndrome.
d) Environmental agents tobacco smoke, possibly charcoal or kerosene
stove.
Less common causes:
a)
b)
c)
d)
e)
f)
g)
h)
i)
j)
k)

Inhaled FB
Cystic fibrosis
Immune deficiency
Congenital lesions TOF, tracheomalacia
Cilliary dyskinesia
Neurological tics, psychogenic cough (habit cough)
GERD
ACE inhibitors
Allergic pneumonitis
Pulmonary hemosiderosis
External compression of trachea-bronchial tree lymph gland, tumours,
etc.

Indicators of presence of specific cough:

Persistent fever with cough

Sudden cough with choking episodes
Progressive cough
Shortness of breath chronic or exertional
Failure to thrive
Hypoxemia
Constitutional symptoms
Clubbing
Hemoptysis
Chest wall abnormality
Noisy breathing
Coughing with a background; h/o recurrent pneumonia
Cough initiates in neonatal period
Swallowing difficulties
Craniofacial abnormality
Neuromuscular disorders

Wet cough lasting more than 3-4 weeks.

Assessment of cough in children:

A) Clinical history and physical examination:
Detailed history and physical examination represent the cornerstones in
the evaluation of the child complaining of cough. It should focus on
duration, quality, triggers, progress and diurnal/ seasonal variation of the
cough, associated symptoms, neonatal history, family history,
environmental exposures, medications and allergic history.
Physical examination should be directed at determining the general wellbeing, vital signs, growth parameters, a detailed respiratory and ENT
examination, nutritional status and certain physical signs, i.e. noisy
breathing and clubbing.
Clinical clues about cough:

Characteristics
Staccato, paroxysmal

2
3
4

Followed by whoop
All day, never during sleep
Burking, brassy

5
6
7
8
9
10

Hoarseness
Abrupt onset
Follows exercise
With eating and drinking
Throat clearing
Productive (sputum)

11

Night cough

12

Seasonal

13

Immunosuppressed children

14
15

Dyspnoea
Animal exposure

16

Geographic

17

Workdays
days off

with

clearing

on

Think of
Pertussis, cystic fibrosis, F.B.
Chlamydia, Mycoplasma
Pertussis
Habit cough
Croup,
habit-cough,tracheomalacia, tracheitis, epiglottitis
Laryngeal involvement (Croup)
F.B., Pulmonary embolism
Reactive airway disease
Aspiration, GERD, TOF
Postnasal drip, vocal tic
Infection,
Cystic
fibrosis,
bronchiectasis
Sinusitis, GERD, reactive airway
disease
Allergic rhinitis, reactive airway
disease
Bacterial
pneumonia,
CMV,
Tuberculosis
Hypoxia, hypercarbia
Chlamydia
psittaci,
Yersinia
pestis, Francisella tularensis, Q
fever, Hantavirus, Histoplasmosis.
Histoplasmosis,
Coccidioidomycosis,
Blastomycosis
Occupational exposure

Red flags:
The following features indicate a possible serious cause of cough which
needs investigations and close follow-up:
A) History:
family history of Lung disease
neonatal onset
sudden onset
hemoptysis
cough with feeding dysphagia, severe vomiting
chronic moist cough with sputum
night sweats, weight loss
continuous unremitting and worsening cough
B) Signs:
Signs of chronic lung disease, clubbing
Failure to thrive
Abnormal voice or crying, inspiratory stridor
Focal chest abnormality
Investigations:
A) Acute Cough:
The majority of acute cough attacks in children are related to
viral/post-viral infections and do not require further
investigations. A chest X-Ray should be considered when
signs indicate lower respiratory tract involvement. If an
inhaled F.B. is suspected as the cause of an acute cough then
urgent bronchoscopy should be done.
B) Chronic cough:
a. Examination of sputum may give hints to the nature of
cough. Clear mucoid sputum is most often associated with an
allergic reaction or a reactive airway disease. Cloudy
(purulent) sputum may indicate infective origin and
bronchiactis but containing eosinophil sputum sometimes
may be found in asthma also. Malodorous expectoration
suggests anerobic infection of the lungs. In cystic fibrosis it is
purulent but rarely foul smelling. Sputum specimens
containing alveolar macrophages only reflect lower
respiratory tract processes. Sputum containing eosinophills
suggests asthma and hypersensitivity reaction. Sputum
macrophages can be stained for haemosiderin content for
diagnosis of pulmonary haemosiderosis. Sputum cuture may
give clue of bacterial pathogens and also AFB for diagnosis of
pulmonary tuberculosis.
b. Other investigations should include blood examination. Chest
radiograph- paranasal signs imaging esophagogram, test for
GERD and lung fuction test at appropriate ages and test of
bronchodilators responses should be considered if applicable.

The extended investigations should be individualised based on

clinical presentations of each patient( feeding/ swallowing
assessment for aspiration, immune work up for immunodeficiency,
sweat chloride test for cystic fibrosis, CT scan for bronchiactasis,
bronchoscopy inhaled FB, and obtain bronchoalveaolar lavage).
Allergy testing (skin prick or radioallergosorben test {Rast} specific
testing) may help if atopy/asthma is likely diagnosis. Other test will
depend on clinical picture and differential diagnosis.

Management of chronic cough in children:

Efforts should be directed to identify the exact underlying cause of

chronic cough in children so that a specific management plan can be
initiated.
Standardise algorithm in the management of different causes of chronic
cough in children to improve clinical outcome.
Evidence based recognition should always be applied to the treatment of
specific
causes,
egasthma,
cystic
fibrosis,
tuberculosis,
immunodeficiency and others.
Chronic cough due to protracted bacterial bronchitis should be managed
by antibiotic sensitive to organisms to about 2-4 weeks period. After which
response to the treatment should be assessed.
Watchful observation with follow up assessment in 6- weeks is
acceptable to healthy children with non specific chronic cough. Empirical
therapies in these children are not recommended.
A trial of anti asthma therapy may be used [inhale corticosteroids] for a
period of 6-8 weeks
Antitussive has a role in cough management only when the cough is too
distressing disturbing sleep and feeds of the patient.
In atopic children with features of allergic rhinitis, the use of intranasal
corticosteroid inhalatons, anti histamine and allergen avoidance are
recommended.
Children with habit cough(psychogenic) may be beneficial from
psychotherapy such as suggestions and behavioural therapy. Organic
cause should be excluded in these children.
There is no place of mucolytic agents including bromhexine or
acetylcysteine as treatment for chronic cough, because there is no
evidence that they work and may cause additional airway irritation (BTS)
When to consider referral for sub specialist adviceGP should consider referring a child to pediatric pulmonologist for
further evaluation in the following situationChronic wet cough not responding to antimicrobial therapy
Specific cough indicating underlying disease

Uncertain diagnosis of chronic non specific cough.

Partially resolved, prolonged or recurrent protracted bronchitis.
FB inhalation
Congenital/ developmental defects.
Chronic cough associated with persisted hypoxemia.
Key points:Chronic cough requires systemic evaluation along with relevant
investigations for specific diagnosis, except when the asthma is etiologic
factor.
In non specific cough a course of bronchodilator can be tried. If the cough
does not resolve within the expected response time, the medication
should be withdrawn and other diagnosis to be considered.
Cough is protective reflex- do not suppress unless it interferes with
feeding/ sleeping.
Avoid irrational cough with multimix cough formula. Use of single active
ingredient is recommended. Steam inhalation may be beneficial as home
remedy.
Avoid environmental contributors if possible eg- tobacco smoke and other
pollutants as allergens.
Cough which is persistent and not responding to initial therapeutic efforts
more specific diagnostic procedures may be warranted.
References:
1. Text book of paediatrics, first SA edition no.2, chapter 384 page 2027.
2. De jongste JC, Shields MD. Cough.2; Chronic cough in children, Thorax
2003, 58-993-1003.
3. Haya Alsubaie, et. al: Approach to cough in children. International
journal of paediatrics and adolescent medicine(2015); 2:38-43.
4. Recommendations for the assessment and management of cough in
children in British thoracic society cough guideline group (2008).
5. Chang AB, Gomb WB, guidelines for evaluations of chronic cough in
paediatrics. ACCP evidence based clinical practice guidelines. Chest
2006 Jasi; 129

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