Article pulmonology

Chronic Cough in Children: A Primary Care and

Subspecialty Collaborative Approach
Robert Kaslovsky, MD,*
Educational Gap
Matthew Sadof, MD†
Cough is an extremely common symptom in children and a cause of great concern. Be-
cause cough can be caused by a wide variety of infectious and noninfectious conditions,
Author Disclosure which will vary among different age groups, clinicians must take a logical approach to
Dr Sadof has disclosed establishing a diagnosis, which will determine appropriate therapy. General pediatricians
no financial must know how to work in coordination with specialists when the cause of the cough is
relationships relevant unknown or complex.
to this article. Dr
Kaslovsky has
Objectives After reading this article, readers should be able to:
disclosed he is
a speaker for Teva 1. Effectively evaluate the multiple causes of cough in children of various ages.
Pharmaceutical 2. Prescribe appropriate therapies for the disorders that cause cough.
Industries LTD. This 3. Understand how to coordinate the care of the generalist with that of the specialist.
commentary does not Cough – cough – cough – cough! A great many parents, grandparents, teachers, and child
contain a discussion of care providers express concern to health care clinicians regarding a child’s cough. Many
an unapproved/ hours of sleep and days of school and work are missed because of a child’s coughing. Simply
investigative use of
suppressing the cough is not the answer because cough is an essential protective mechanism
to keep the airways patent and clear. Well-meaning parents and grandparents often are
a commercial product/
quick to use over-the-counter products to suppress the cough, usually with no relief
device. and occasionally with significant toxic effects.
Treatment of cough is not a “one size fits all” proposition. Rather, the clinician must
evaluate each case of cough individually and determine treatment according to the cause of
the cough. It is important to consider the age of the child, the nature and timing of the
cough (wet or dry, day or night), and the presence of other symptoms and signs that
can reveal the cause of the cough. Although most of the evaluation begins in the medical
home with the primary care clinician, subspecialists (pediatric
pulmonologists and allergists) often are called on to assist in
the evaluation and treatment of cough. The following case
Abbreviations vignettes illustrate some of the common conditions for which
AAP: American Academy of Pediatrics the primary manifestation may be coughing.
ATAQ: Asthma Therapy Assessment Questionnaire
ACT: Asthma Control Test Cough in the Infant
ACQ: Asthma Control Questionnaire Common causes of cough in infants are listed in Table 1.
CDC: Centers for Disease Control and Prevention
CF: cystic fibrosis Case 1
CT: computed tomography An 8-month-old girl has had a cough on and off for
DTP: diphtheria and tetanus toxoids and pertussis 2 months. The cough is worse with eating and lying down,
FEV1: forced expiratory volume in 1 second and at times her cry is hoarse. She had respiratory syncytial
GERD: gastroesophageal reflux disease virus (RSV) bronchiolitis at age 4 months, requiring 2 nights
ICS: inhaled corticosteroid in the hospital while receiving supplemental oxygen. She has
NHLBI: National Heart, Lung, and Blood Institute not had wheezing. She attends child care with 9 other chil-
RSV: respiratory syncytial virus dren her age in the classroom. Child care providers have
TEF: tracheoesophageal fistula sent her home on several occasions because of persistent
VCD: vocal cord dysfunction coughing, sometimes with spitting up after eating. Her

*Department of Pediatrics, Albany Medical College, Albany, NY.

†
Department of Pediatrics, Baystate Children’s Hospital, Springfield, MA.

498 Pediatrics in Review Vol.34 No.11 November 2013


Causes of Cough in
Table 1.
Infancy (1)
Asthma – consider family history
Aspiration – ask about choking with feedings, rattly
breathing after feedings
Congenital airway disease – laryngomalacia,
tracheomalacia, tracheoesophageal fistula, vascular
compression of the airways
Cystic fibrosis (normal newborn screening does not
completely exclude cystic fibrosis)
Infections – Chlamydia, pertussis, viruses, maternally
transmitted tuberculosis
Other – environmental tobacco smoke, pollution,
congenital heart disease, idiopathic hemosiderosis
immunizations are up to date; she takes no medication
and has no allergies. The family history is positive for past
asthma in the mother; the father smokes, but the mother
insists the smoking is exclusively outside the house.
Physical examination reveals an afebrile infant with
a respiratory rate of 24 breaths per minute, heart beat
of 100 beats per minute, and oxygen saturation of 99%
on room air. She has pale, swollen nasal mucosa with clear
discharge; findings of examination of the eyes, ears, and
throat are normal. Her chest has a normal shape, and no
retractions are noted. Auscultation reveals occasional ex-
piratory wheezes bilaterally. Her cardiac and abdominal
examination findings are normal. She has no finger club-
bing and no rash.
Primary Care Approach
Young children cannot report their own symptoms.
Therefore, the practitioner is presented with the parental
perception of the cough and associated symptoms. The
timing and inciting and relieving factors may vary from
patient to patient, with some parents being better able
to give a more reliable history than others. Items of his-
tory to consider are listed in Table 2.
In this case, the girl’s attendance at a large child care
facility suggests an infectious cause of her cough. RSV,
influenza, human metapneumovirus, adenovirus, and rhi-
novirus are all frequent pathogens in this age group, yet
the chronicity of her cough makes acute infection less
likely. The absence of fever makes an acute bacterial pro-
cess, such as from Streptococcus pneumoniae, Haemophilus
influenzae, or Chlamydia, less likely. Her previous immu-
nizations (which at this age should have included pneu-
mococcal, H influenzae type B, and pertussis vaccines)
decrease the likelihood of these entities as well.
pulmonology chronic cough
Focused History for
Table 2.
Cough
Age of child
Nature of cough
Stridor or wheezing
Timing and season
Sputum, presence and character
Exposure to infection
Response to previous therapy
Family history of atopy, asthma, eczema, cystic fibrosis
The hoarseness of the infant’s cry could point to
viral or allergic croup (laryngotracheitis), yet the asso-
ciation with feedings and worsening of the cough sug-
gests gastroesophageal reflux disease (GERD). Cough
after feeding also may occur with a tracheoesophageal
fistula (TEF), but this condition usually is associated
with frequent pneumonia, which is not present in this
patient.
The absence of prematurity also makes bronchopul-
monary dysplasia less likely. This child has a history of
RSV infection that may point to a history of underlying
reactive airway disease.
The physical examination findings for cough may be
normal on any given day. Table 3 lists components of a fo-
cused examination for cough. Her examination does not
reveal any signs of poor nutrition and growth. Cystic fi-
brosis (CF) can present with a chronic cough; there may
or may not be an associated failure to gain weight. An in-
creased anterior-posterior thoracic diameter in this situa-
tion would point to chronic lung disease, which can
include poorly controlled reactive airway disease or other
disorders. The presence of wheezing in the absence of
a heart murmur makes congestive heart failure an unlikely
cause in this patient. The pale boggy nasal mucosa along
with the hoarse cry may suggest an atopic child; the ab-
sence of eczema does not exclude atopy. Clubbing, due
to hyperostosis of the distal phalanx, which is suggestive
of chronic hypoxia, is not present, making serious chronic
lung disease less likely.
Testing that can be performed or ordered from the
primary care practitioner’s office may include procedures
listed in Table 4.
A chest radiograph and sinus radiograph may be or-
dered by the primary care physician. The chest radiograph
in asthma may reveal hyperinflation or peribronchial cuff-
ing or may reveal entirely normal findings. Sinus radio-
graphs are of questionable utility in this age range given
Pediatrics in Review Vol.34 No.11 November 2013 499
pulmonology chronic cough

evaluation so far, including radiographic images and test

Focused Examination for
Table 3. reports, will help to focus the visit. This previsit com-
munication serves several important functions. By cre-
Cough ating a focus for the subspecialist, the communication
Nutrition and growth
improves the patient experience and decreases the num-
Upper respiratory tract – ears, nose, and sinuses ber of repetitive tests, reducing discomfort and cost to
Chest – Anterior-posterior thoracic diameter, lung the patient. This dialogue also helps the primary care
sounds, cardiac examination physician to become more educated on how to ap-
Extremities – clubbing proach this problem best.
Skin – eczema
Specialist Approach
This child’s history includes intermittent cough, a history
that only the maxillary sinuses are aerated and not com-
of RSV bronchiolitis, and prolonged expiration and expi-
pletely. Sputum is hard to obtain because children of this
ratory wheezes on examination. According to the Mod-
age often swallow their phlegm. Given the recurrent na-
ified Asthma Predictive Index, (2,3) infants who have 3
ture of this cough, a complete blood cell count with an
or more wheezing episodes may have asthma. Major risk
eosinophil count and quantitative immunoglobulin mea-
factors for asthma include parental history of asthma, per-
surement can be useful in this age group. Eosinophilia
sonal history of atopic dermatitis, and sensitivity to 1 or
or an elevated IgE level would suggest an allergic process.
more aeroallergens. Minor risk factors (that require 2 or
Decreased IgA or IgG or one of the IgG subclasses would
more to indicate asthma) include food allergy, wheezing
point to an immunodeficiency. Given the recurrent nature
in the absence of infection, and eosinophilia of 4% or more.
of this cough, a sweat chloride test to rule out CF also
This patient’s mother has a history of asthma in child-
would be indicated, although the CF newborn screening
hood, which she said she “outgrew.” (When asked about
result was negative.
symptoms with infection, she admitted to having occa-
At this point, it would be best to start a trial of inhaled
sional “bronchitis” and to needing an inhaler occasion-
albuterol and schedule a follow-up visit in a few weeks. If
ally, suggesting that her asthma is still present.)
a positive response is obtained, an inhaled corticosteroid
Once asthma is suspected, a trial of therapy may be
(ICS), preferably with an appropriately sized chamber
useful because young infants and toddlers cannot per-
and mask or by nebulizer, would be indicated. Depend-
form pulmonary function testing. Administration of an
ing on the comfort level of the generalist, this trial can be
inhaled bronchodilator in the office, looking for signifi-
performed before referral to the subspecialist.
cant clearing of the wheezing, may be helpful. If no major
response is noted, a trial of oral corticosteroids or ICSs,
Preparing for Subspecialty Referral
with continued use of an inhaled bronchodilator, should
If the results of all the above tests are normal and the need
be tried. Follow-up in a few weeks should be performed
for albuterol is persistent, consultation with a pediatric
by either the specialist or the primary care physician.
pulmonologist would be indicated. It is important for
In this case, the child’s wheezing cleared in 10 minutes
the primary care physician to know the medical home
after albuterol was administered. By 3 weeks of inhaled bu-
neighborhood and develop a working relationship with
desonide treatment, the cough had ceased all together. A
local subspecialists. A previsit telephone call to the pedi-
diagnosis of asthma was made, and the patient continued
atric pulmonologist or a note that summarizes the
to take inhaled budesonide. This ICS therapy should be
continued, even in the absence of symptoms, because
asthma control is maintained by the ICS.
As the primary care physician develops a relationship
Tests Ordered at the
Table 4. with the pulmonologist in the medical home neighbor-
Primary Care Office hood, he or she will become more confident in knowing
when to start ICS therapy in such a patient and when to
Radiographs – chest, sinuses refer to the pediatric pulmonologist for annual review,
Sputum Gram stain and culture guidance, and decisions about duration of ICS therapy.
Complete blood cell count, eosinophil count, IgG, IgA,
The National Heart, Lung, and Blood Institute (NHLBI)
IgM, and IgE, possibly IgG subclasses
Sweat chloride measurement Expert Panel –Report 3 recommends follow-up every 1 to
3 months with a physician. (4)

500 Pediatrics in Review Vol.34 No.11 November 2013


Cough in the Toddler
Common causes of cough in toddlers are listed in Table 5.
Case 2
A 3-year-old boy presents in the summer with a nonpro-
ductive cough that has been present for 3 to 4 weeks. The
cough started with no signs of respiratory infection. The
child has had no rhinorrhea, he has not been febrile, and
there has been no witnessed choking episode. The cough
is worse with running, and although, initially, night cough
had been a problem, currently there is no significant night-
time cough. In the past, the boy has experienced cough
with colds, but not for such a prolonged time. His
mother has been giving him an over-the-counter cough
and cold preparation but reports that it does not decrease
the cough and makes him “hyper.” There is no family his-
tory of asthma or eczema. There is no reported environ-
mental smoke exposure. He has not attended child care.
Physical examination reveals an afebrile child who has
a respiratory rate of 28 breaths per minute, heart rate of
80 beats per minute, and oxygen saturation of 96% on
room air. He is a well-nourished boy who has normal
ears, nose, and throat examination findings and no retrac-
tions of the chest. Auscultation reveals decreased aeration
of the left lower side of the chest but no crackles or
wheezes. Cardiac and abdominal findings are normal.
There is no digital clubbing or rash.
Primary Care Approach
A cough that is exacerbated with running in this age
group can indicate asthma, yet the absence of wheezing,
eczema, and rhinorrhea makes asthma less likely. Summer
is a time when the prevalence of respiratory infections is
low and there is less attendance at child care, making in-
fection an unlikely possibility. Sinusitis is a consideration
in this age group. The maxillary sinuses are well aerated at
this time, but the frontal sinuses have yet to develop. The
Causes of Cough in
Table 5.
Toddlers and Early
Childhood (1)
Asthma (with or without wheezing)
Bronchiectasis – cystic fibrosis, ciliary dyskinesia,
immunodeficiency, postinfectious
Chronic middle ear disease, allergy, sinusitis
Foreign body in airways
Pulmonary hemosiderosis
pulmonology chronic cough
absence of nasal discharge and presence of normal mu-
cosa make sinusitis less likely. There are no reported risk
factors for atopy (such as family or personal history of
eczema, asthma, or significant allergy), making atopy an
unlikely diagnosis. The most concerning portion of the
physical examination findings here is the decreased aera-
tion in the left lower side of the chest.
Although there was no witnessed choking episode,
a high degree of suspicion for foreign body aspiration
must be in the primary physician’s mind any time a tod-
dler presents with unexplained cough, wheezing, or stri-
dor of acute onset. If pediatric radiology services are not
immediately available, referral to the specialist would be
appropriate at this point. If radiology services are avail-
able, inspiratory and expiratory (or lateral decubitus) ra-
diographs of the chest would be indicated. If these studies
demonstrate localized air trapping, or atelectasis, such
findings would imply obstruction of a bronchus, possibly
due to a retained foreign body. A density in the left lower
lobe would be concerning and may represent atelectasis,
a congenital anomaly of the lung (cyst, hamartoma, or
sequestration), or a retained foreign body, even in the ab-
sence of witnessed choking. Pneumonia is not likely in
this setting because the child has no fever or other signs
of such illness.
Preparing for Subspecialty Referral
The primary care physician should consider consultation
with a pulmonologist at this point, requesting a further
evaluation. Again, a previsit contact with the specialist
can help speed up the evaluation and clarify the next
steps. Questions that may be discussed include the
following:
• Should sinus radiography or computed tomography
(CT) of the sinuses be performed?
• Should an upper gastrointestinal series with fluoros-
copy be performed?
• Should bronchoscopy or CT be performed if a chest
radiograph reveals opacity in the lung?
Specialist Approach
This child has a cough with no signs of infection and no
history compatible with asthma or atopy. In toddlers,
one should always ask about a choking episode, but
not every aspiration episode is witnessed by an adult.
The localized lung findings make imaging studies the
next logical step.
If there is a visible density on the chest radiograph,
then pneumonia, atelectasis, or congenital pulmonary
malformation may be considered. Because most aspirated
Pediatrics in Review Vol.34 No.11 November 2013 501
pulmonology chronic cough

materials are nonmetallic (food or plastics), they will not

be visible on plain radiographs. The specialist should be
consulted early if the results of plain chest radiographs are
negative or if the primary care physician strongly suspects
an aspirated foreign body based on history.
Diagnosis of a foreign body aspiration can be confirmed
by flexible bronchoscopy. However, because of the small
size of the airways and scopes, removal of a foreign body
usually requires surgeons to perform rigid bronchoscopy
to stabilize the airway and allow passage of instruments
to grab or suction out the foreign object. Once removal
is accomplished, a thorough examination of the entire tra-
cheobronchial tree should be performed to be sure that
the foreign body removed is the only one that is present.
In a review of 1,068 foreign body aspirations in chil-
dren, the authors found 3% in the larynx, 13% in the tra- Figure 1. Air trapping in the left lung, suggestive of left mainstem
bronchial obstruction.
chea, 52% in the right main bronchus, 6% in the right
lower lobe bronchus, less than 1% in the right middle respite from his symptoms. The patient has been sleeping
lobe bronchus, 18% in the left main bronchus, and 5% comfortably, with no night cough.
in the left lower lobe bronchus; 2% were bilateral. (5) Immediately on entering the examination room, the
In this case, the toddler had air trapping in the left practitioner notes a harsh, barking cough, which persists
lung (Fig 1). Flexible bronchoscopy was performed, with throughout the entire examination. Physical examination
the finding of a tan foreign object occluding the left reveals a respiratory rate of 16 breaths per minute, heart
mainstem bronchus (Fig 2). At rigid bronchoscopy, half rate of 70 beats per minute, and oxygen saturation of
of a peanut was removed from the child’s airway. He 99%. The boy has pale nasal mucosa and no subconjunc-
made an uneventful recovery and was sent home the next tival hemorrhages. There is no sinus tenderness, and the
morning, free of cough. tympanic membranes are normal in appearance. His chest
Because of the acute nature of the presentation, barium has normal shape, and his lungs are clear bilaterally. Car-
swallow, sinus radiographs, and a trial of corticosteroids diac, abdominal, and extremity examination findings are
and bronchodilator probably would not be necessary. In normal. There is no cyanosis, clubbing, or eczema.
the case of a patient with new onset of diffuse wheezing,
a trial of bronchodilator and corticosteroids might help dif- Primary Care Approach
ferentiate the child with asthma, but even children with This previously healthy adolescent is experiencing a cough
asthma can aspirate foreign objects. that represents a change in his usual health. Given the

Cough in the Adolescent

Common causes of cough in adolescents are listed in
Table 6.

Case 3
A 15-year-old boy presents in midwinter with increased
coughing during 6 to 8 weeks. The cough started with
mild coryza. Over time, it has become a harsh, barking,
repetitive cough that occurs several times per minute for
hours on end. There have been several instances in which
the cough has led to vomiting. There has been no fever,
no wheezing, and no further nasal symptoms since the
first week. When he was an infant, the boy was hospital-
ized because of bronchiolitis and was treated for eczema.
He tends to have spring and fall rhinorrhea. Over-the-
counter cough medications have provided only a brief Figure 2. A foreign body in the left main stem bronchus.

502 Pediatrics in Review Vol.34 No.11 November 2013


Causes of Cough in
Table 6.
Adolescents (1)
Asthma
Bronchiectasis – postinfectious
Ciliary dyskinesia
Immunodeficiency
Cystic fibrosis
Infection: viral, Mycoplasma, fungal
Middle ear disease
Smoking
Occupational exposure
Psychogenic cough
Sinusitis/postnasal drip
Chest tumor
prior history of eczema and bronchiolitis, asthma is one of
the first conditions to consider. Further inquiry should
focus on a history of prolonged cough with colds, with
or without associated wheezing, and a history of prior al-
buterol use. Inquiry should be made about smoking and
a family history of asthma. It is important to recognize
that adolescents may be reluctant to disclose asthma
and other chronic illness to their peers, particularly in
midadolescence, when the influence of the peer group
is at its highest. They may reject parental and physician
advice to use an inhaler before exercise as well.
A more extensive history is needed to detect alterna-
tive causes of cough. A history of regurgitation or epigas-
tric discomfort that may be associated with some burning
in the back of the throat or a frequent sour taste suggests
GERD. This disorder also may be associated with recur-
rent sinus disease or recurrent otitis. Smoking history
should include inquiry about smoking tobacco or mari-
juana or the use of inhalants, as well as second-hand
smoke exposure.
The patient also should be asked about other environ-
mental exposures, specifically, frequent visits to nail sa-
lons, use of solvents in school art class, or vocational
classes such as cosmetology, wood or metal shop, auto-
body class, or automotive repair shop. People who work
in farming environments also are at risk for environmen-
tal lung diseases.
Are there stressors in this patient’s life that may be in-
ducing a habit-related cough or vocal cord dysfunction?
The HEADSS (6) is a quick adolescent psychosocial
screen that can be used here. If appropriate, the pediatric
symptom checklist also may be administered to screen
for underlying mental health issues. This list can be
pulmonology chronic cough
accessed at http://www.brightfutures.org/mentalhealth/
pdf/professionals/ped_sympton_chklst.pdf.
The use of over-the-counter cough preparations must
be addressed. Many of these cough preparations are in-
effective. In fact, demulcents such as honey have been
found to be more effective in suppressing cough when
compared with dextromethorphan. (7) Over-the-counter
cough preparations are not harmless. (8) In practice,
these preparations frequently are misused by adolescents
and inappropriately dosed by parents. (9)
In 2007, the Food and Drug Administration recom-
mended that cough and cold preparations not be used
in children younger than 2 years and that these prepa-
rations be used only with caution in older children. (10)
In 2011, a large number of prescription cough suppres-
sant and multisymptom cough preparations were re-
moved from the market in the United States. (11)
For a more detailed review of over-the-counter cough
preparations and their toxic effects, the reader is re-
ferred to a recent Pediatrics in Review article by Pappas
and Hendley. (12)
Again, it is important to work closely with the pediat-
ric pulmonologist, and a previsit contact is helpful in co-
ordinating an approach to the patient and in helping
prepare this adolescent for the pulmonologist visit.
Specialist Approach
Chronic cough in adolescents can arise from a number of
conditions (Table 6). In this case, the first consideration
is to decide whether the patient has an infection causing
his cough or if the patient has underlying asthma as the
cause of the symptoms. Spirometry with bronchodilator
use at rest may be helpful. Even in patients in whom the
initial results are normal, a large change with inhaled
bronchodilator would be indicative of asthma.
If spirometry findings are normal with no bronchodi-
lator response, lung volumes by plethysmography (“body
box”) may reveal air trapping (elevated residual volume
to total lung capacity ratio), which may indicate asthma.
Methacholine challenge testing to elicit bronchospasm
(as seen by a decrease in the forced expiratory volume
in 1 second [FEV1]) in susceptible individuals is per-
formed only in cases in which the resting spirometry re-
sult is entirely normal. Normal spirometry in the face of
symptoms does not necessarily exclude a diagnosis of
asthma.
This patient attempted spirometry but coughed so
hard he could not complete the maneuver. His cough
did not change after a dose of albuterol. Although asthma
remains in the differential diagnosis, other disorders should
be considered.
Pediatrics in Review Vol.34 No.11 November 2013 503
pulmonology chronic cough
Infections such as pertussis and Mycoplasma infection
are possibilities. Adolescents and adults with waning im-
munity and mild symptoms can be an important reservoir
of pertussis. The Advisory Committee on Immuniza-
tion Practices recommends that all adolescents receive
adult diphtheria and tetanus toxoids and pertussis (DTP)
vaccine, beginning at age 10 or 11 years, depending
on product selection (http://www.cdc.gov/vaccines/
acip/index.html). An elevated white blood cell count with
lymphocytosis may be present in patients who have
pertussis.
Another possible infection in this age group is Myco-
plasma disease. Symptoms of Mycoplasma infection are
milder and include chest pain, chills, cough that usually
is dry and not bloody, excessive sweating, fever, head-
ache, and sore throat. Lymphocytosis is not a prominent
feature, and findings of chest radiography may be normal
or may reveal lobar pneumonia. The results of chest and
sinus radiography in this patient were normal.
A more thorough history should be obtained in con-
sideration of conditions such as bronchiectasis, which
may be postinfectious, ciliary dyskinesia (which often is
accompanied by chronic middle ear disease), immunode-
ficiency, or CF. This patient has no history of chronic
respiratory disease and has normal growth parameters,
making those disorders less likely. With normal chest
imaging results, a mediastinal cyst or tumor, which can
compress airways and cause cough, is not likely in this
adolescent.
An important consideration for any adolescent patient
who has a persistent cough is psychogenic or habit cough.
In this particular patient, the nature of the cough was un-
usually forced, with a barky or honking quality, and the
cough ceased with sleep. The keys to recognition of this
disorder are lack of an identifiable cause and complete
cessation of the cough with sleep.
Habit cough may begin with a viral infection that
causes airway irritation. The cough cycle is perpetuated
by secondary gain, such as parental attention or exclu-
sion from school. Preexisting stressors may or may
not be determined easily. In other circumstances, emo-
tional stress precipitates the behavior that leads to the
cough. Hypnosis, counseling, or suggestion therapy of-
ten is successful in treatment. The pulmonologist may
refer the adolescent back to the medical home, where
the primary care physician can arrange for mental health
evaluation or perhaps administer suggestion or hypno-
sis therapy. This patient was diagnosed as having hab-
it cough and was referred for counseling, and his
habit cough improved after his underlying anxiety was
addressed.
504 Pediatrics in Review Vol.34 No.11 November 2013
A video example of habit cough is available in the article
“Pseudo-asthma: When Cough, Wheezing, and Dyspnea
Are Not Asthma” by Miles Weinberger and Mutasim Abu-
Hasan, featured in the October 2007 issue of Pediatrics
(http://pediatrics.aappublications.org/content/suppl/
2007/10/03/120.4.855.DC1/fig_2007-0078-File007.
mov).
Pathophysiology of Cough
Cough is an important protective mechanism required to
maintain the patency of the airways and keep them clear
of retained secretions. Cough receptors are found along
the surface of the pharynx, larynx, trachea, and major
bronchi. They are located also in the middle ear, sinuses,
pericardium, and diaphragm. Cough is a brainstem reflex
but also is under voluntary control (eg, “take a deep
breath and cough”). (1,13) The afferent neural pathway
is from receptors via vagal pathways (cranial nerve X) to
the medulla of the brain. The efferent neural pathway is
from the cerebral cortex and medulla via the vagus and
superior laryngeal nerves to the glottis, external intercos-
tals, diaphragm, and other major inspiratory and expira-
tory muscles.
Cough receptors can become unresponsive to re-
peated stimulation, as may be the case in chronic aspira-
tion or when there is a retained foreign body. (5) Cough
provides a milking action of secretions and propels
them upward by high-velocity airflow. In patients with
weak or absent cough, retained secretions can lead
to lower airway infections and serious morbidity or
mortality.
Cough involves 3 phases: deep inspiration, compres-
sion, and exhalation. On deep inhalation, the airways
open and the lungs inflate. The glottis then closes, and
the abdominal and internal intercostal muscles contract,
resulting in increased pressure in the lungs. The glottis
then opens, causing air to rush out of the lungs at high
velocity. (14)
A cough of more than 3 to 4 weeks’ duration is defined
as a chronic cough in the pediatric literature. (15,16)
History and Physical Findings to Consider by
Age
A large portion of the primary care physician’s day
is spent listening to families and patients talk about
cough. A thorough history will guide the approach to
diagnosis and treatment. The age of the child, the
nature and timing of the cough, the time of year, and
the response to therapy will guide evaluation and
management.

Cough in the Newborn and Early Infancy
In this age group, eliciting the timing and associated activ-
ities of the cough is critical. Cough after feeding may rep-
resent overfeeding, GERD, or a TEF. If the cough stops
after a decrease in the volume of the feedings, overfeeding
is the likely cause. If the cough worsens with feedings or is
associated with vomiting, GERD is the probable cause. If
the cough worsens after feedings and there is no associated
vomiting, a TEF should be considered. Both GERD and
TEF can be associated with wheezing, cyanosis, and ta-
chypnea that worsen after feeding (Table 1).
An elevated respiratory rate is another important diag-
nostic clue. When cough is associated with tachypnea in
the presence of a normal, elevated, or decreased body
temperature, sepsis must be considered. When associated
with cyanosis that is relieved by the administration of ox-
ygen, an intrapulmonary process should be considered. If
the cyanosis is not diminished with oxygen, congenital
heart disease with right-to-left shunting or a more severe
pulmonary process might be present. If this finding oc-
curs, with or without a heart murmur, a cardiac evalua-
tion, including electrocardiography, 4 extremity blood
pressures, and chest radiography, must be performed,
along with subspecialty consultation.
As the child ages through infancy, additional causes
for acute and chronic cough should be considered.
RSV infection is a common cause of wheezing and
cough. Although most RSV-infected infants experience
upper respiratory tract symptoms, only 1 of 4 will de-
velop lower respiratory tract disease characterized by
wheezing. Most healthy infants who develop RSV bron-
chiolitis do not require hospitalization, and most who
are hospitalized improve with supportive care and are
discharged in fewer than 5 days. Some infants at risk
for severe RSV disease will require more intensive sup-
port, such as preterm infants and those with cyanotic con-
genital heart disease or immunodeficiency. Some children
who contract RSV early in life will develop reactive airway
disease; the mechanism of this association is poorly
understood.
Specific treatment guidelines for RSV infection are
presented in the Red Book of the American Academy of
Pediatrics (AAP). (17) Current information about RSV
can be found on the Centers for Disease Control and Pre-
vention (CDC) website (http://www.cdc.gov/rsv/).
If the cough is staccato and occurs in the first few
months of life, it may be a result of Chlamydia trachoma-
tis pneumonia. Often a history of maternal Chlamydia in-
fection or a history of mucoid conjunctivitis in the infant
during the end of the second week of life points to this
pulmonology chronic cough
diagnosis. However, absence of eye drainage does not
preclude this diagnosis.
Pertussis also may cause coughing, often associated
with apnea spells in the infant, who may not have com-
plete immunity after only 1 or 2 immunizations. If the
cough is paroxysmal, it may be due to a Bordetella pertus-
sis infection, which often requires hospitalization in
infancy. B pertussis infection, also known as whooping
cough or the 100-day cough, is transmitted via aerosol-
ized droplets. The incubation period is 7 to 10 days, with
a range of 5 to 21 days. Adolescents and adults with wan-
ing immunity, especially if they have not been immunized
with the DTP vaccine, may have mild symptoms and can
be an important reservoir of pertussis.
There are 3 stages of pertussis: catarrhal, paroxysmal,
and convalescent. Patients are most contagious during
the catarrhal phase, presenting with a mild cough and
low-grade fever. The paroxysmal phase, characterized
by a paroxysmal cough followed by a characteristic inspi-
ratory whoop (although this sign may be absent in in-
fants) lasts for up to 10 weeks. The convalescent phase
is characterized by gradual resolution of symptoms for
weeks to a few months, which can become worse again
with subsequent viral infections.
Although culture is the gold standard, it is important
to remember that B pertussis is a fastidious organism and
many cultures test falsely negative. Polymerase chain re-
action and B pertussis–specific antibody testing are avail-
able but not yet licensed for diagnostic use. Diagnostic
clues include a leukocytosis with a lymphocytic predom-
inance in infants and small children but not always in ado-
lescents. Infants suspected of having pertussis must be
observed for apnea. Other complications include subcon-
junctival hemorrhage, subdural hemorrhages, primary
and secondary pneumonia, and atelectasis.
Specific treatment guidelines for pertussis are pre-
sented in the AAP Red Book. (17) Current information
about pertussis can be found on the CDC website
(http://www.cdc.gov/pertussis/index.html).
Cough in a Toddler
As mentioned, the Modified Asthma Predictive index is
a helpful tool for diagnosing asthma in toddlers who can-
not perform spirometry. (2,3) Bronchiectasis may be
present if the child has CF, ciliary dyskinesia, or immuno-
deficiency or has had serious pulmonary infections in the
past. The cough of bronchiectasis is described as a wet
cough, yet toddlers usually cannot expectorate sputum
for testing. Chest radiography or CT can help make this
diagnosis.
Pediatrics in Review Vol.34 No.11 November 2013 505
pulmonology chronic cough
Chronic middle ear disease, allergy, and sinusitis are all
conditions in which the cough receptors in the middle ear
or upper airway are stimulated chronically. These condi-
tions, although not directly involving the lungs, can be
major triggers of chronic coughing. Foreign body in air-
ways always should be considered.
Pulmonary hemosiderosis is a rare disease, occurring
primarily in children, that causes recurrent episodes of
diffuse alveolar hemorrhage. Recurrent alveolar bleeding
may eventually produce pulmonary hemosiderosis and fi-
brosis. Diffuse alveolar hemorrhage is characterized by
cough, leading to hemoptysis, dyspnea, alveolar opacities
on chest radiographs, and anemia, and can result from
a variety of underlying conditions. Hypersensitivity to
milk (Heiner syndrome) or the mold Stachybotrys are 2
reported causes of this condition. (18,19)
Cough in an Adolescent
Asthma is a common condition in all age groups. By ad-
olescence, office-based spirometry, specialty-based plethys-
mography, and exhaled nitric oxide measurements may
be helpful tools. The NHLBI issued updated asthma
guidelines in 2007. These guidelines apply at every
age, with a specific section devoted to patients older than
12 years. The document gives practitioners a tool for as-
sessing initial severity based on domains of severity and
risk, spirometry to measure FEV1 , and the FEV 1 to
forced vital capacity ratio. At subsequent visits, asthma
control is assessed using similar domains, often with
use of standardized questionnaires such as the Asthma
Control Questionnaire (ACQ), Asthma Control Test
(ACT; (http://www.asthmacontrol.com/), and Asthma
Therapy Assessment Questionnaire (ATAQ). (20)
Well-controlled asthma is defined by the presence of
all of the following: daytime symptoms less than twice
a week, nighttime awakenings less than twice a month,
no disturbance of exercise tolerance, and use of short-
acting b-agonists for symptoms less than twice a week.
Spirometry, if available at the primary care office, should
reveal an FEV1 greater than 80% of the predicted value
in patients who have well-controlled asthma. In ad-
dition, the risk domain should reveal 1 or fewer emer-
gency department visits for asthma or courses of oral
corticosteroids for exacerbations in the last 6 months.
Strict adherence to the classification scheme is important
because adolescents often say their asthma is controlled
even when having daily symptoms. (3)
The guidelines also recommend use of written asthma
action plans to help adolescents and their families manage
routine and sick day treatments. Two meta-analyses of
506 Pediatrics in Review Vol.34 No.11 November 2013
action plans for children and adolescents confirm the ef-
ficacy of such plans in reducing the risk of exacerbations
that lead to acute care visits and suggest that symptom-
based plans may be superior to peak flow–based plans,
possibly due to better and more persistent adherence
with symptom-based plans. (21,22) A recent study in
adult asthmatic women who were given action plans
found a higher level of satisfaction with the asthma care
they received and better adherence with their asthma
medications. (23)
The written asthma action plan should include the
following information: instructions for handling ex-
acerbations (including self-administration of medication),
recommendations for long-term control medications, pre-
vention of exercise-induced bronchospasm, and identifica-
tion and avoidance of triggers. The adolescent should be
involved in developing the action plan and should provide
a copy to the school nurse. (24)
As in the younger child, bronchiectasis can be an issue
in adolescence. This disorder can be associated with un-
derlying processes that are associated with impaired secre-
tion clearance, such as ciliary dyskinesia, CF, and smoking.
As in younger patients, middle ear disease and sinusitis
with postnasal drip also can be associated with chronic
cough. GERD can be a cause or an effect of chronic
coughing in adolescents and can be worsened by smok-
ing, alcohol consumption, overeating, or binging. Psycho-
genic or habit cough, as illustrated in the case above, is
a diagnosis of exclusion.
Chest tumors, although uncommon, should be in the
differential in an adolescent with a chronic cough. Tu-
mors may be detected on chest imaging performed for
other reasons, or the patient may present with signs of
airway obstruction. For a more complete discussion
on chest tumors, refer to the AAP publication Pediatric
Pulmonology (http://ebooks.aap.org/product/pediatric-
pulmonology).
Vocal cord dysfunction (VCD) is a paroxysmal closure
of the vocal cords (often associated with stress or exer-
tion) that can mimic exercise-induced asthma, with sud-
den symptoms of inability to breathe. (25) As many as
30% to 50% of patients with VCD also may have asthma,
but a careful history of inspiratory difficulty will help the
practitioner identify VCD. Treatment is not medication
but counseling or speech therapy. Hypnosis also has been
used for diagnosis and treatment of VCD. (26)
Effective Comanagement
At times, the primary care clinician may need to make a
referral to a pediatric pulmonologist. The timing of this

referral can vary and depends on the level of experience of
the primary care practitioner, the availability of the pedi-
atric pulmonologist, and the seriousness of the child’s
illness. In general, a pediatric pulmonologist should be
consulted for all patients who have required an intensive
care admission for respiratory distress, who have moderate
and severe persistent asthma, who are born with congen-
ital airway anomalies, and who pose diagnostic dilemmas.
Patients with chronic illnesses, such as bronchopulmonary
dysplasia, CF, and neuromuscular diseases, often are co-
managed with pediatric pulmonologists.
The cases presented above illustrate the causes and
evaluation of cough and include suggestions as to how
the primary care physician and the pediatric pulmonolo-
gist can collaborate. Effective comanagement strategies
can ensure a smoother experience for families. To help
coordinate roles and communication among primary
care practitioners, specialists, patients, and their families,
a training module has been developed by the National
Center of Medical Home Initiatives for Children with
Special Health Care Needs (http://www.medicalhomeinfo.
org/training/cme/event2.aspx). This tool includes templates
for comanagement, various helpful letters, care-sharing agree-
ments, and comanagement and previsit telephone calls.
Summary
• Chronic cough in an infant, child, or adolescent can be
challenging to diagnose and treat. Simple cough
suppression is not the appropriate approach.
• The primary care physician should review the
differential diagnosis; perform a careful history,
physical examination, and laboratory evaluation; and,
depending on evaluation results, often collaborate
with the pulmonologist.
• A strong suspicion of asthma in all age groups is
appropriate, but all cough should not simply be
ascribed to asthma.
• Good communication among the primary care
physician, specialist, patient, and family is the key to
making the diagnosis, which will lead to appropriate
therapy.
References
1. Chernick V, Boat TF, Wilmott RW, Bush A, eds. Kendig’s
Disorders of the Respiratory Tract in Children. 6th ed. Philadelphia,
PA: WB Saunders and Company; 1998
2. Castro-Rodríguez JA, Holberg CJ, Wright AL, Martinez FD. A
clinical index to define risk of asthma in young children with re-
current wheezing. Am J Respir Crit Care Med. 2000;162(4 pt 1):
1403–1406
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3. Guilbert TW, Morgan WJ, Zeiger RS, et al. Atopic character-
istics of children with recurrent wheezing at high risk for the
development of childhood asthma. J Allergy Clin Immunol. 2004;
114(6):1282–1287
4. National Heart, Lung, and Blood Institute. Guidelines for the
Diagnosis and Management of Asthma (EPR-3). www.nhlbi.nih.
gov/guidelines/asthma. Accessed January 8, 2013.
5. Eren S, Balci AE, Dikici B, Doblan M, Eren MN. Foreign body
aspiration in children: experience of 1160 cases. Ann Trop Paediatr.
2003;23(1):31–37
6. Goldenring JM, Rosen D. Getting into adolescent heads: an
essential update. Contemp Pediatr. 2004;21(1):64–90
7. Paul IM, Beiler J, McMonagle A, Shaffer ML, Duda L, Berlin
CM Jr. Effect of honey, dextromethorphan, and no treatment on
nocturnal cough and sleep quality for coughing children and
their parents. Arch Pediatr Adolesc Med. 2007;161(12):1140–
1146
8. Schaefer MK, Shehab N, Cohen AL, Budnitz DS. Adverse
events from cough and cold medications in children. Pediatrics.
2008;121(4):783–787
9. Lokker N, Sanders L, Perrin EM, et al. Parental misinterpre-
tations of over-the-counter pediatric cough and cold medication
labels. Pediatrics. 2009;123(6):1464–1471
10. Public Health Advisory. FDA Recommends that Over-the-
Counter (OTC) Cough and Cold Products Not Be Used for
Infants and Children Under 2 Years of Age. http://www.fda.gov/
drugs/drugsafety/postmarketdrugsafetyinformationforpatient-
sandproviders/drugsafetyinformationforheathcareprofessionals/
publichealthadvisories/ucm051137.htm. Accessed January 3,
2013.
11. Department of Health and Human Services, Food and Drug
Administration. Drugs for human use; unapproved and misbranded
oral drugs labeled for prescription use and offered for relief
of symptoms of cold, cough [docket No. FDA-2011-N-0100].
Federal Register. 2011;76(42):11794. http://www.gpo.gov/fdsys/
pkg/FR-2011-03-03/pdf/2011-4703.pdf. Accessed January 3,
2013.
12. Pappas DE, Hendley JO. The common cold and decongestant
therapy. Pediatr Rev. 2011;32(2):47–55
13. Chang AB. Cough, cough receptors, and asthma in children.
Pediatr Pulmonol. 1999;28(1):59–70
14. Cough Reflex – Physiology, Process, Ear-Cough Reflexes.
http://www.healthhype.com/cough-reflex-physiology-process-ear-
cough-reflexes.html. Accessed January 8, 2013.
15. Hay AD, Wilson A, Fahey T, Peters TJ. The duration
of acute cough in pre-school children presenting to primary
care: a prospective cohort study. Fam Pract. 2003;20(6):
696–705
16. Hay AD, Wilson AD. The natural history of acute cough in
children aged 0 to 4 years in primary care: a systematic review. Br J
Gen Pract. 2002;52(478):401–409
17. Pickering LK, ed. Red Book: 2012 Report of the Committee on
Infectious Diseases. 29th ed. Elk Grove Village, IL: American
Academy of Pediatrics: 2012.
18. Boat TF, Polmar SH, Whitman V, Kleinerman JI, Stern
RC, Doershuk CF. Hyperreactivity to cow milk in young
children with pulmonary hemosiderosis and cor pulmonale
secondary to nasopharyngeal obstruction. J Pediatr. 1975;
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19. Centers for Disease Control and Prevention (CDC). Acute
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January 1993-November 1994. MMWR Morb Mortal Wkly Rep.
1994;43(48):881–883
20. Halbert RJ, Tinkelman DG, Globe DR, Lin SL. Measuring
asthma control is the first step to patient management: a literature
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21. Ducharme FM, Bhogal SK. The role of written action plans in
childhood asthma. Curr Opin Allergy Clin Immunol. 2008;8(2):
177–188
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randomized controlled trials examining written action plans in
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157–163
23. Patel MR, Valerio MA, Sanders G, Thomas LJ, Clark NM.
Asthma action plans and patient satisfaction among women with
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24. Bruzzese JM, Evans D, Kattan M. School-based asthma
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tion: classification and treatment. Laryngoscope. 2012;122(4):844–
853
26. Anbar RD, Hehir DA. Hypnosis as a diagnostic modality for
vocal cord dysfunction. Pediatrics. 2000;106(6):E81
Suggested Reading
Sadof M, Kaslovsky R. Adolescent asthma: a developmental ap-
proach. Curr Opin Pediatr. 2011;23(4):373–378
Weinberger M, Abu-Hasan M Exercise-induced dyspnea in chil-
dren and adolescents: if not asthma then what? Ann Allergy
Asthma Immunol. 2005;120(4):366–371

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Some clinical signs are highly suggestive of a given condition. In the scenarios below, match the clinical
presentation with the most likely cause of the patient’s cough.
1. A 1-month-old girl with a staccato cough and conjunctivitis.
A. Bordetella pertussis infection.
B. Bronchopulmonary dysplasia.
C. Chlamydia trachomatis pneumonia.
D. Cystic fibrosis.
E. Gastroesophageal reflux disease.

2. A 2-month-old girl born at 27 weeks’ gestation who has had increasing cough for the past few weeks.
A. Bordetella pertussis infection.
B. Bronchopulmonary dysplasia.
C. Chlamydia trachomatis pneumonia.
D. Cystic fibrosis.
E. Gastroesophageal reflux disease.

3. A 3-month-old boy with an intermittent cough that is worse with eating and lying down.
A. Bordetella pertussis infection.
B. Bronchopulmonary dysplasia.
C. Chlamydia trachomatis pneumonia.
D. Cystic fibrosis.
E. Gastroesophageal reflux disease.

508 Pediatrics in Review Vol.34 No.11 November 2013

 pulmonology chronic cough

4. A 5-year-old boy with failure to thrive who has had a cough for several months.
A. Bordetella pertussis infection.
B. Bronchopulmonary dysplasia.
C. Chlamydia trachomatis pneumonia.
D. Cystic fibrosis.
E. Gastroesophageal reflux disease.

5. A 13-year-old boy with a persistent cough who reports burning in the back of his throat.
A. Bordetella pertussis infection.
B. Bronchopulmonary dysplasia.
C. Chlamydia trachomatis pneumonia.
D. Cystic fibrosis.
E. Gastroesophageal reflux disease.

Poetic License
Cough, both acute and chronic
Isn’t helped by OTC tonics.
The diagnostic spiral
Includes GERD and things viral
RSV, influenza, pneumonic.
–MCM

Parent Resources From the AAP at HealthyChildren.org

• English: http://www.healthychildren.org/English/family-life/health-management/pediatric-specialists/Pages/What-is-a-
Pediatric-Pulmonologist.aspx
• Spanish: http://www.healthychildren.org/spanish/family-life/health-management/pediatric-specialists/paginas/what-is-
a-pediatric-pulmonologist.aspx

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