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)

Phlegmy cough

Viral infection

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

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].