Cough in children

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

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. 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 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

Differentiating [disease name] from other Diseases

For further information about the differential diagnosis, click here.

Epidemiology and Demographics

• The prevalence of [disease name] is approximately [number or range] per 100,000 individuals worldwide.
• In [year], the incidence of [disease name] was estimated to be [number or range] cases per 100,000 individuals in [location].

Age

• Patients of all age groups may develop [disease name].

• [Disease name] is more commonly observed among patients aged [age range] years old.
• [Disease name] is more commonly observed among [elderly patients/young patients/children].

Gender

• [Disease name] affects men and women equally.

• [Gender 1] are more commonly affected with [disease name] than [gender 2].
• The [gender 1] to [Gender 2] ratio is approximately [number > 1] to 1.

Race

• There is no racial predilection for [disease name].

• [Disease name] usually affects individuals of the [race 1] race.
• [Race 2] individuals are less likely to develop [disease name].

Risk Factors

• Common risk factors in the development of [disease name] are [risk factor 1], [risk factor 2], [risk factor 3], and [risk factor 4].

Natural History, Complications and Prognosis

• The majority of patients with [disease name] remain asymptomatic for [duration/years].
• Early clinical features include [manifestation 1], [manifestation 2], and [manifestation 3].
• If left untreated, [#%] of patients with [disease name] may progress to develop [manifestation 1], [manifestation 2], and [manifestation 3].
• Common complications of [disease name] include [complication 1], [complication 2], and [complication 3].
• 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 [disease name] is made when at least [number] of the following [number] diagnostic criteria are met:

• [criterion 1]
• [criterion 2]
• [criterion 3]
• [criterion 4]

Symptoms

• [Disease name] is usually asymptomatic.
• Symptoms of [disease name] may include the following:

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

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].