Cough in children

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Marufa Marium, M.B.B.S[2]

Synonyms and keywords: Cough in kids

Historical Perspective

• The word Cough was first derived from the middle English Coughen or old English Cohhian which was primarily composed of the middle Dutch Kochen and the high middle German Kuchen, in early 14th century.

Classification

• Cough in children may be classified or defined according to the duration of presenting complaints, quality and sound, causes of cough into several groups.:
• 1 Duration of Presenting complaints: According to the duration of cough, it can be sub classified into three categories.
  • Acute: Cough persists for less than three weeks.
  • Subacute: Cough persists for three to eight weeks.
  • Chronic: Cough persists for more than eight weeks.

• 2. Nature or Quality and sounds: According to the quality and sound cough can be sub classified in to following categories-
  • Dry or Hacking or Nonproductive.
  • Wet or productive cough.
  • Staccato or short repetitive cough.
  • Whooping or paroxysmal violent or spasmodic cough.
  • Barking cough: Brassy barking or Honking barking.
  • Phlegmy cough.
  • Burning cough.

• 3. Causes of Cough: Based on causes cough is subdivided into following three sub groups-
  • Normal or expected cough.
  • Specific cough.
  • Non-specific cough.

• 4. Anatomic classification on causes of cough: Cough can be produced from different anatomical locations. for example-
  • Nose and Paranasal sinuses.
  • Pharynx.
  • Larynx.
  • Trachea and Bronchi.
  • Pulmonary parenchyma.
  • Pleura.
  • Mediastinum.
  • Heart and blood vessels.
  • External ear and Tympanic membrane.
  • Esophagus.

• 5. Grades of cough: Cough can be graded into four main sub categories-
  • Eutussia or Normal.
  • Hypertussia or Sensitized.
  • Hypotussia or Desensitized.
  • Dystussia or Pathological.
  • Atussia or Absent.

Cough in children can also be classified under infectious (Bacterial, Viral, fungal, Parasitic) or non-infectous categories broadly.

Pathophysiology

• Cough is natural innate primitive reflex that helps in mucocilliary clearance of foreign particles and secretions from respiratory tracts. It is also a defensive mechanism protecting respiratory airways from aspiration of pathogens, particulates and secretions. A complex arc comprised of neuro-respiratory pathways helps in initiating the cough reflex.

Mechanical and chemical stimulation of cough receptors (Rapidly adapting receptors, slowly adapting receptors or C-fibers) in Respiratory airways

Afferent pathways: Sensory nerve fibers via Vagus Nerve from ciliated columnar epithelium of upper airways, cardiac and esophageal branches from diaphragm send impulse to central cough center

Central cough center in upper brain stem medulla and pons send impulse of sequence of phases (Inspiratory, Compressive, Expiratory) for constituting cough

Efferent pathways: The nucleus retroambigualis sends impulse via phrenic and spinal motor nerves to diaphragm and abdominal and respiratory muscles, the nucleus ambiguous sends impulse to larynx by laryngeal branches of vagus nerve

• On gross pathology, Bloody, Serous , Mucoid, Rusty, Pink frothy, and Purulent are characteristic findings of sputum produced by coughing.
• On microscopic histopathological analysis, Pathogens, RBCs, Leukocytes, epithelial celss are characteristic findings of Sputum produced by coughing.

Causes

Causes of cough in children according to duration:

According to quality and sound of cough in children, the causes can be classified according to following chart.

Dry or Hacking or Nonproductive

Sinusitis, Tonsillitis, Pharyngitis, Allergic Rhinitis, GERD, Asthma, Environmental exposure to irritants(pollen, dust, mites, smokes), Post infectious cough.

Wet or productive cough

Cystic fibrosis, Bronchiectasis, Bronchiolitis, Tuberculosis, Rhinitis, Postnasal drip, Pneumonia, Emphysema, Acute bronchitis, Asthma

Causes of Cough based on Nature or quality and sound

Staccato or short repetitive cough

Chlamydia pneumonia

Whooping or paroxysmal violent or spasmodic cough

Pertussis

Barking cough

•Brassy barking: Croup, Tracheomalacia, Laryngitis, Tracheitis •Honking barking: Psychogenic cough , Tourette syndrome (habit cough)

Stridor

Viral Croup, Epiglottis, Bacterial tracheitis, Retropharyngeal and peritonsilar abscess

Burning cough

Bacterial Bronchitis, Irritants

Based on anatomical location the causes of cough in children can be demonstrated into following chart-

Nose and Paranasal sinuses

Rhinitis, Foreign Body, Sinusitis, Nasal polyp, ppHypertrophied inferior turbinate]]

Pharynx

Pharyngitis, Foreign Body, Irritants

Larynx

Laryngitis, Epiglottis, Tonsillitis, Laryngomalacia, Subglottic stenosis, Foreign body

Trachea and Bronchi

Tracheitis, Croup, Bronchiolitis, Bronchiectasis, Bronchitis, Cystic fibrosis

Causes based on anatomic location

Pulmonary parenchyma

Pneumonia, Tuberculosis, Environmental toxin, Respiratory distress syndrome, Aspiration syndrome, Hypersensitivity Pneumonitis, Connective tissue disease, Alveolar capillary dysplasia, Neuroendocrine cell hyperplasia of infancy, Medications, Mutations causing surfactant dysfunction, Emphysema

Pleura

Pleurisy, Pneumothorax, Hemothorax, Parapneumonic effusions, Pleural tuberculosis, Congenital hydrothorax and chylothorax

Mediastinum

Mediastinitis, Mediastinal Tuberculosis, Thymoma, Thymic hyperplasia, Thymic carcinoma, Neuroblastoma, Ganglioneuroma, Non Hodgkin lymphoma, Sarcoma, Mature teratoma, Endodermal sinus tumor, Hemangioma, Wilms tumor, Lymphangioma

Heart and blood vessels

Congenital heart disease, Valvular heart disease, Heart failure, Myocarditis, Cardiomyopathies, Wegener granulomatosis, Vasculitis, Arteriovenous malformation

External ear and Tympanic membrane

Otitis media and externa, Impaction of foreign body, wax, Myringitis

Esophagus

GERD, Tracheoesophageal Fistula

Differentiating Cough from other Diseases

Organ system		Diseases	Clinical manifestations								Diagnosis				Other features
			Symptoms							Physical exam
			Onset	Duration	Productive cough	Hemoptysis	Weight lost	Fever	Dyspnea	Ascultation	Lab findings	Imaging	PFT	Gold standard
Respiratory	Upper airway diseases	Epiglottitis	Abrupt or acute	12−24 hours	−	−	−	+	+	Stridor Hoarseness	Elevated white blood count in CBC Blood culture may show bacterial growth Epiglottal culture in intubated patients may show bacterial growth	Enlarge epiglottis (>8 mm), loss of vallecular air space and distended hypopharynx in neck X−ray may be helpful	Normal function	Direct visualization of erythematous and edematous epiglottis	Tripod posture Drooling Tenderness of the anterior part of the neck Etiology: Haemophilus influenzae
		Croup	Acute	3−5 days	+	−	−	+	+	Stridor Crackles	Leukopenia	Subglottic narrowing (steeple sign) in postero−anterior radiograph chest	Decresed tidal volume	Clinical diagnosis. Laboratory findings and imaging are not necessary for diagnosis	Barking cough Etiology: Parainfluenza virus type 1 (most common)
		Pertussis	Acute	Two weeks	+ Whooping sound	−	+	+	+	Clear chest	Polymerase chain reaction (PCR) shows Bordetella pertussis Serologic testing	Atelectasis may seen on chest imaging Lymphadenopathy	Normal function	Culture	Etiology: Bordetella pertussis Phases: Catarrhal, paroxysmal and convalescent
		Common Cold	Acute	3−10 days	+	−	−	+	−	Rales Wheezing	Bacterial culture is not indicated	Chest X−Ray in patients with signs of consolidation	Normal function	Clinical diagnosis	Conjunctival injection Nasal congestion
		Seasonal Influenza	Acute	5−10 days	−	−	−	+	+	Shorteness of breath	RT−PCR Antigen detection test	Reticular or reticulonodular opacities in chest X−Ray	Normal function	Clinical diagnosis	Etiology: A or B Influenza virus
		Rhinosinusitis	Acute, subacute, chronic, recurrent	Acute: Less than 4 weeks Subacute: 4−12 weeks Chronic: More than 12 weeks Recurrent: 4 or more episodes or acute rhinosinusitis per year	+	−	−	+	+	Clear chest	In complicated acute bacterial rhinosinusitis, endoscopic cultures or sinus aspirate is indicated Nasal culture may also be helpful	Air−fluid level, mucosal edema and bony erosion of sinus on CT MRI for distinguish the etiology	Normal function	Clinical diagnosis: Nasal congestion, obstruction, and purulent rhinorrhea	Erythema in periorbital area
		Organ system		Diseases	Clinical manifestations								Diagnosis				Other features
Symptoms							Physical exam
Onset	Duration	Productive cough	Hemoptysis	Weight lost	Fever	Dyspnea	Ascultation	Lab findings	Imaging	PFT	Gold standard
Respiratory	Lower airway	Asthma	Chronic	Years	+ Clear mucoid or yellow sputum	−	−	−	+	Wheezing (expiratory) Rales Rhonchi	Eosinophilia Total serum IgE in test for allergy may be helpful	Normal airways in chest X−ray CT if there any abnormality in chest X−Ray	FEV1/FVC ratio <70% and FEV1 >15% increase after 15 minutes of 2 puffs of beta 2 sympathomimetic drug After physical active FEV1 decreases by >15% After inhaled corticosteroid (ICS)FEV1 increased by >15%	Airflow limitation on spirometry	Family history Seasonal variation
		Acute Bronchitis	Acute	From 5 days to 1 or 3 weeks	+	−	−	+/−	+	Wheezing Rhonchi	Sputum culture is not indicated PCR in bacterial infection may be helpful	Chest X−ray to exclude other diseases	FEV1 < 80%	Clinical diagnosis	Majority of cases are caused by respiratory viruses
		Non−asthmatic eosinophilic bronchitis	Chronic	More than 8 weeks	+ Eosinophilic sputum	−	−	−	+	Wheezing Shortness of breath	High levels of IgE Airway eosinophilia in sputum induction or bronchial wash fluid from bronchoscopy (bronchoalveolar lavage)	Normal chest X−Ray	FEV1/FVC >70% No response of short acting bronchodilator	Bronchial biopsy Eosinophilia	Exposure to an occupational cause
		Bronchiectasis	Chronic	Months to years	+ Mucopurulent sputum	+	−	−	+	Crackles Wheezing Shortness of breath	Complete blood count (CBC) IgG, IgM and IgA Sputum culture for fungi, bacteria and mycobacteria	Linear atelectasis and dilated airways in chest X−Ray	FEV1/FVC <70% Normal FVC Low levels of FEV1	CT of chest	Digital clubbing Recurrent pleurisy
		Emphysema	Chronic	Months to years	+ Mucoid or purulent sputum	−	−	+	+	Shortness of breath Wheezing Prolonged expiration Crackles	Testing for alpha 1−antitrypsin may be helpful	Chest X−Ray to exclude other diseases CT may also be helpful	FEV1/FVC <70% Post bronchodilator FEV1 >80	Detection of early emphysema in CT of chest	Exposure of tobacco and air pollution
		Foreing body aspiration	Acute	Variable	+	+	−	+	+	Wheezing Decreased breath sounds	No specific tests	Hyperinflated lungs, atelectasis, and mediastinitis Shift in chest radiograph when the object is radio−opaque CT may be helpful	Not specific	Bronchoscopy	In children <1 year and adults >75 years Organic materials in children Inorganic materials in adults
		Bronchiolitis	Acute	8−15 days	+	−	−	+	+	Wheezing Crackles Increased respiratory rate	Complete blood count (CBC) may be helpful Urinalysis & urine culture ( in infants)	Chest X−Ray may be helpful	Normal function or obstructive changes (FEV1/FVC <70%) Air trapping in Lung volumes Reduced Diffusing capacity of carbon monoxide ( DLCO)	Clinical diagnosis	Etiology: Respiratory syncytial virus, Rhinovirus Children <2 years
		Organ system		Diseases	Clinical manifestations								Diagnosis				Other features
Symptoms							Physical exam
Onset	Duration	Productive cough	Hemoptysis	Weight lost	Fever	Dyspnea	Ascultation	Lab findings	Imaging	PFT	Gold standard
Respiratory	Parenchyma	Pneumonia	Acute	Variable	+ Mucopurulent sputum	−	−	+	+	Crackles Egophony Decreased bronchial sounds	Leftward shift leukocytosis Blood culture in hospitalized patients Sputum culture in hospitalized patients	Consolidation, cavitation, and infiltrated interstitial in chest X−ray Anatomical changes observed in chest CT	Not specific	Infiltration observed in chest X−ray	Community−acquired pneumonia Healthcare−associated pneumonia
		Tuberculosis (TB)	Chronic	More than 2 or 3 weeks	+	+	+	+	+	Pleural effusion Crackles Whispered pectoriloquy Decreased fremitus Rhonchi	Sputum acid−fast bacilli (AFB) smear may be positive Mycobacterial culture may be positive Molecular testing may be helpful	Reactivation of TB is observed as infiltration in the upper lobe in chest X−Ray In patients with HIV, Tb is observed as lobar infiltration, adenopathy, lung mass named tuberculoma, small fibronodular lesions, and/or pleural effusion on chest X−Ray CT can detect early nodal process	Decreased FEV1 Reduced FVC	Isolation of Mycobacterium tuberculosis from some secretion	Etiology: Mycobacterium tuberculosis Complications: Pneumothorax, bronchiectasis, pulmonary destruction and chronic pulmonary aspergillosis
		Cystic fibrosis (CF)	Chronic	Variable	+	−	+	+/−	+	Barrel−shaped chest Wheezing Tachypnea	Respiratory tract culture may be helpful for diagnosing secondary bacterial infection Bronchoalveolar lavage for cytology may be helpful ≥ 60 mmol/L Sweat chloride test CFTR mutation in molecular testing may be positive	Hyperinflation, atelectasis, and infiltrates on chest X−Ray Severe patients present bronchietasis, "tram tracks" peribronchial cuffing in chest X−Ray The extension of bronchietasis can be defined by CT	RV/TLC ratio increased FEV1/FVC ratio <70% Low levels of FEV1 High levels of TLC RV increased	Sweat chloride test	Evidence of CFTR dysfunction
		Organ system		Diseases	Clinical manifestations								Diagnosis				Other features
					Symptoms							Physical exam
					Onset	Duration	Productive cough	Hemoptysis	Weight lost	Fever	Dyspnea	Ascultation	Lab findings	Imaging	PFT	Gold standard
Cardiac
		Gastrointestinal		Gastroesophageal reflux	Chronic	Variable	+	−	+	−	+	Wheezing Hoarseness	Not specific	Upper endoscopy may be helpful Barium esophagram may be helpful	Normal function	PH testing	−−
		Organ system		Diseases	Clinical manifestations								Diagnosis				Other features
Symptoms							Physical exam
Onset	Duration	Productive cough	Hemoptysis	Weight lost	Fever	Dyspnea	Ascultation	Lab findings	Imaging	PFT	Gold standard
Autoimmune		Goodpasture syndrome	Chronic	Variable	−	+	−	−	+	Shortness of breath	The following investigations may be helpful: Complete blood count (CBC) ANCA positive Anti−GBM in ELISA or western blot	Pulmonary infiltratation in chest X−Ray CT scan for parenchymal involvement	Increased DLCO Decreased TLC Decreased FVC	Renal biopsy	Hematuria Proteinuria
		Wegener's disease (GPA)	Chronic	Months	+	+	+	+	+	Hoarseness Stridor Wheezing	The following investigations may be helpful: ANCA, P−ANCA, C−ANCA BUN Creatinine Complete blood count Urinalysis Lung biopsy	Nodules, pulmonary infiltrates, reticular margins, pleural opacities and cavities in chest X−Ray Nodules, cavities and stellate−shaped peripherial pulmonary in chest CT Bronchoscopy may be helpful	Low levels of DLCO Reduce lung volumes	Tissue biopsy	Nasal crusting, sinus pain, chronic rhinosinusitis, nasal obstruction and discharge in upper airway Saddle nose deformity Purpura in lower extremities

Epidemiology and Demographics

• Cough is one of the most common symptoms of children in outpatient department.
• Ninety percent of acute cough in children is resolved within three weeks. The prevalence of Chronic Cough in children is approximately 5% to 10% in USA according to American Academy of Pediatrics.

Age

• Cough is more commonly observed among children under 5 years of age.

Gender

• Boys are more commonly affected with cough than girls.

Race

• There are racial predilection for certain causes of Cough in children. Asthma is predominant in Blacks and American Indians or Alaska native while Cystic fibrosis, Wegener's granulomatosis are more frequently affecting Caucasians according to American Lung Association.

Risk Factors

• Common risk factors in the development of Cough in children are-
  • Preterm Birth and delivery by caesarian section.
  • Respiratory Distress Syndrome.
  • Congenital Heart Disease.
  • Age less than 1 year.
  • Maternal Influenza vaccination.
  • Malnutrition.
  • Secondary exposure to tobacco smoke.
  • Air pollutants, Mold, Inadequate ventilation.
  • Immunodeficiencies.
  • Daycare attendance.
  • History of Atopy.
  • Household pets.
  • Low socioeconomic status.

Natural History, Complications and Prognosis

• The majority of patients with acute cough have recovery within three weeks in 90% of cases. Some of cases are progressed to sub-acute and chronic phases. Chronic cough lasts more than eight weeks whereas recurrent cough can affect a child for more than two years with 1-2 weeks duration in each episodes.
• Early clinical features include frequent episodes of coughing, Runny nose, Sneezing, Low grade fever, Sore Throat, Night Sweats, Arching Back, Irritability, Failure to thrive, Fussiness, Chocking sensation(Foreign body impaction).
• If left untreated, Cough can cause following complication in children.

• Prognosis is generally [excellent/good/poor], and the [1/5/10­year mortality/survival rate] of patients with [disease name] is approximately [#%].

Diagnosis

Diagnostic Criteria

• The diagnosis of Causes of Cough is made after a detailed history, presenting complaints and physical examination and laboratory findings in some cases. Cough can be classified according to-
  • Duration.
  • Nature or quality of cough.
  • Etiology.
  • Anatomic location.
  • Grade.

A detailed history focusing on onset of disease, factors worsening the episodes, time of worsening, aleviating factors, amount work of breathing, presence of shortness of breathing, relation with vomiting, food intake, posture, presence of blood, systemic findings(fever, weight loss, hypotension, syncope, vertigo, dizziness, failure to thrive), episodes of chocking, houshold socioeconomic status, family history, drug abuse and smoking in family members, atopy, congenital history. The following sighns are alarming which need further emergent evaluation by the physician.

• Cyanosis or hypoxemia or hypoxia
• Respiratory distress
• Stridor
• Toxic appearence
• Weight loss

Symptoms

• Symptoms of Cough may include the following:

• Breathelessness and episodes of coughing
• Sneezing
• Fever
• Sore Throat
• Night Sweats
• Arching Back
• Irritability
• Failure to thrive
• Fussiness
• Chocking sensation(Foreign body impaction)
• Chills and Rigor
• Wheezing
• Headache, myalgia, fatigue

Physical Examination

• Patients with [disease name] usually appear [general appearance].
• Physical examination may be remarkable for:

• [finding 1]
• [finding 2]
• [finding 3]
• [finding 4]
• [finding 5]
• [finding 6]

Laboratory Findings

• There are no specific laboratory findings associated with [disease name].

• A [positive/negative] [test name] is diagnostic of [disease name].
• An [elevated/reduced] concentration of [serum/blood/urinary/CSF/other] [lab test] is diagnostic of [disease name].
• Other laboratory findings consistent with the diagnosis of [disease name] include [abnormal test 1], [abnormal test 2], and [abnormal test 3].

Electrocardiogram

There are no ECG findings associated with [disease name].

OR

An ECG may be helpful in the diagnosis of [disease name]. Findings on an ECG suggestive of/diagnostic of [disease name] include [finding 1], [finding 2], and [finding 3].

X-ray

There are no x-ray findings associated with [disease name].

OR

An x-ray may be helpful in the diagnosis of [disease name]. Findings on an x-ray suggestive of/diagnostic of [disease name] include [finding 1], [finding 2], and [finding 3].

OR

There are no x-ray findings associated with [disease name]. However, an x-ray may be helpful in the diagnosis of complications of [disease name], which include [complication 1], [complication 2], and [complication 3].

Echocardiography or Ultrasound

There are no echocardiography/ultrasound findings associated with [disease name].

OR

Echocardiography/ultrasound may be helpful in the diagnosis of [disease name]. Findings on an echocardiography/ultrasound suggestive of/diagnostic of [disease name] include [finding 1], [finding 2], and [finding 3].

OR

There are no echocardiography/ultrasound findings associated with [disease name]. However, an echocardiography/ultrasound may be helpful in the diagnosis of complications of [disease name], which include [complication 1], [complication 2], and [complication 3].

CT scan

There are no CT scan findings associated with [disease name].

OR

[Location] CT scan may be helpful in the diagnosis of [disease name]. Findings on CT scan suggestive of/diagnostic of [disease name] include [finding 1], [finding 2], and [finding 3].

OR

There are no CT scan findings associated with [disease name]. However, a CT scan may be helpful in the diagnosis of complications of [disease name], which include [complication 1], [complication 2], and [complication 3].

MRI

There are no MRI findings associated with [disease name].

OR

[Location] MRI may be helpful in the diagnosis of [disease name]. Findings on MRI suggestive of/diagnostic of [disease name] include [finding 1], [finding 2], and [finding 3].

OR

There are no MRI findings associated with [disease name]. However, a MRI may be helpful in the diagnosis of complications of [disease name], which include [complication 1], [complication 2], and [complication 3].

Other Imaging Findings

There are no other imaging findings associated with [disease name].

OR

[Imaging modality] may be helpful in the diagnosis of [disease name]. Findings on an [imaging modality] suggestive of/diagnostic of [disease name] include [finding 1], [finding 2], and [finding 3].

Other Diagnostic Studies

• [Disease name] may also be diagnosed using [diagnostic study name].
• Findings on [diagnostic study name] include [finding 1], [finding 2], and [finding 3].

Treatment

Medical Therapy

• There is no treatment for [disease name]; the mainstay of therapy is supportive care.

• The mainstay of therapy for [disease name] is [medical therapy 1] and [medical therapy 2].
• [Medical therapy 1] acts by [mechanism of action 1].
• Response to [medical therapy 1] can be monitored with [test/physical finding/imaging] every [frequency/duration].

Surgery

• Surgery is the mainstay of therapy for [disease name].
• [Surgical procedure] in conjunction with [chemotherapy/radiation] is the most common approach to the treatment of [disease name].
• [Surgical procedure] can only be performed for patients with [disease stage] [disease name].

Prevention

• There are no primary preventive measures available for [disease name].

• Effective measures for the primary prevention of [disease name] include [measure1], [measure2], and [measure3].

• Once diagnosed and successfully treated, patients with [disease name] are followed-up every [duration]. Follow-up testing includes [test 1], [test 2], and [test 3].