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Cough in Children

by Deborah M. Consolini, MD

Cough is a reflex that helps clear the airways of secretions, protects the airway from foreign body aspiration, and can be the manifesting symptom of a disease. Cough is one of the most common complaints for which parents bring their children to a health care practitioner.

Etiology

Causes of cough differ depending on whether the symptoms are acute (< 4 wk) or chronic (see Some Causes of Cough in Children).

For acute cough , the most common cause is

  • Viral URI

For chronic cough , the most common causes are

  • Asthma (most common)

  • Gastroesophageal reflux disorder (GERD)

  • Postnasal drip

Foreign body aspiration and diseases such as cystic fibrosis and primary ciliary dyskinesia are less common, although they can all result in persistent cough.

Some Causes of Cough in Children

Cause

Suggestive Findings

Diagnostic Approach

Acute

Bacterial tracheitis (rare)

URI-like prodrome, stridor, barky cough, high fever, respiratory distress, toxic appearance, purulent secretions

Anteroposterior and lateral neck x-rays

Possibly bronchoscopy

Bronchiolitis

Rhinorrhea, tachypnea, wheezing, crackles, retractions, nasal flaring, possible posttussive emesis

In infants up to 24 mo; most common among those 3–6 mo

Clinical evaluation

Sometimes chest x-ray

Sometimes nasal swab for rapid viral antigen assays or viral culture

Croup

URI-like prodrome, barky cough (worsening at night), stridor, nasal flaring, retractions, tachypnea

Clinical evaluation

Sometimes anteroposterior and lateral neck x-rays

Environmental pulmonary toxicants

Exposure to tobacco smoke, perfume, or ambient pollutants

Clinical evaluation

Epiglottitis (rare)

Abrupt onset, high fever, irritability, marked anxiety, stridor, respiratory distress, drooling, toxic appearance

If patient is stable and clinical suspicion is low, lateral neck x-ray

Otherwise, examination in operating room with direct laryngoscopy

Foreign body

Sudden onset of cough and/or choking

No fever initially

No URI prodrome

Chest x-ray (inspiratory and expiratory views)

Sometimes bronchoscopy

Pneumonia (viral, bacterial)

Viral: URI prodrome, fever, wheezing, staccato-like or paroxysmal cough, possible muscle soreness or pleuritic chest pain

Possible increased work of breathing, diffuse rales, rhonchi, or wheezing

Bacterial: Fever, ill appearance, chest pain, shortness of breath, possible stomach pain or vomiting

Signs of focal consolidation including localized rales, rhonchi, decreased breath sounds, egophony, and dullness to percussion

Chest x-ray

URI

Rhinorrhea, red swollen nasal mucosa, possible fever and sore throat, shotty cervical adenopathy (many small nontender nodes)

Clinical evaluation

Chronic*

Airway lesions (tracheomalacia, TEF)

Tracheomalacia: Congenital stridor or barky cough, possible respiratory distress

TEF: History of polyhydramnios (if accompanied by esophageal atresia), cough or respiratory distress with feeding, recurrent pneumonia

Tracheomalacia: Airway fluoroscopy and/or bronchoscopy

TEF: Attempt passage of a catheter into the stomach (helps in diagnosis of TEF with esophageal atresia)

Chest x-ray

Contrast swallowing study, including esophagography

Bronchoscopy and endoscopy

Asthma

Intermittent episodes of cough with exercise, allergens, weather changes, or URIs

Nighttime cough

Family history of asthma

History of eczema or allergic rhinitis

Clinical evaluation

Trial of asthma drugs

Pulmonary function tests

Atypical pneumonia (mycoplasma, Chlamydia)

Gradual onset of illness

Headache, malaise, muscle soreness

Possible ear pain, rhinitis, and sore throat

Possible wheezing and crackles

Persistent staccato cough

Chest x-ray

PCR testing

Birth defects of the lungs (eg, congenital adenomatoid malformation)

Several episodes of pneumonia in the same part of the lungs

Chest x-ray

Sometimes CT or MRI

Cystic fibrosis

History of meconium ileus, recurrent pneumonia or wheezing, failure to thrive, foul-smelling stools, clubbing or cyanosis of nail beds

Sweat chloride test

Molecular diagnosis with direct mutation analysis

Foreign body

History of acute onset of cough and choking followed by a period of persistent cough

Possible development of fever

No URI prodrome

Presence of small objects or toys near child

Chest x-ray (inspiratory and expiratory views)

Bronchoscopy

Gastroesophageal reflux

Infants and toddlers: History of spitting up after feedings, irritability with feeding, stiffening and arching of the back (Sandifer syndrome), failure to thrive, recurrent wheezing or pneumonia

Older children and adolescents: Chest pain or heartburn after meals and lying down, nighttime cough, wheezing, hoarseness, halitosis, water brash, nausea, abdominal pain, regurgitation

Infants: Clinical evaluation

Sometimes upper GI study for determination of anatomy

Trial of H 2 blockers or a proton pump inhibitor

Possible esophageal pH or impedance probe study

Older children: Clinical evaluation

Trial of H 2 blockers or proton pump inhibitors

Possible endoscopy

Pertussis or parapertussis

1–2 wk catarrhal phase of mild URI symptoms, progression to paroxysmal cough, difficulty eating, apneic episodes in infants, inspiratory whoop in older children, posttussive emesis

Intranasal specimen for bacterial culture and PCR

Allergic rhinitis with postnasal drip

Headache, itchy eyes, sore throat, pale nasal turbinates, cobblestoning of posterior oropharynx, history of allergies, nighttime cough

Trial of antihistamine and/or intranasal steroids

Possible trial of a leukotriene inhibitor

Postrespiratory tract infection

History of respiratory infection followed by a persistent, staccato cough

Clinical evaluation

Primary ciliary dyskinesia

History of repeated upper (otitis media, sinusitis) and lower (pneumonia) respiratory tract infections

Chest x-ray

Sinus x-ray or CT

Chest CT

Microscopic examination of living tissue (typically from sinus or airway mucosa) for cilia abnormalities

Psychogenic cough

Persistent barky cough, possibly prominent during classes and absent during play and at night

No fevers or other symptoms

Clinical evaluation

Tuberculosis (TB)

History or risk of exposure

Immunocompromise

Sometimes fever, chills, night sweats, lymphadenopathy, weight loss

PPD

Sputum culture (or morning gastric aspirate culture for children < 5 yr)

Interferon-gamma release assay (especially if there is a history of BCG vaccination)

Chest x-ray

*All patients require a chest x-ray when they present for the first time with chronic cough.

MIF = microimmunofluorescent; TEF = tracheoesophageal fistula.

Evaluation

History

History of present illness should cover duration and quality of cough (barky, staccato, paroxysmal) and onset (sudden or indolent). The physician should ask about associated symptoms. Some of these symptoms are ubiquitous (eg, runny nose, sore throat, fever); others may suggest a specific cause: headache, itchy eyes, and sore throat (postnasal drip); wheezing and cough with exertion (asthma); night sweats (TB); and spitting up, irritability, or arching of the back after feedings in infants (gastroesophageal reflux). For children 6 mo to 6 yr, the parents should be asked about potential for foreign body aspiration, including older siblings or visitors with small toys, access to small objects, and consumption of small, smooth foods (eg, peanuts, grapes).

Review of systems should note symptoms of possible causes, including abdominal pain (some bacterial pneumonias), weight loss or poor weight gain and foul-smelling stools (cystic fibrosis), and muscle soreness (possible association with viral illness or atypical pneumonia but usually not with bacterial pneumonia).

Past medical history should cover recent respiratory infections, repeated pneumonias, history of known allergies or asthma, risk factors for TB (eg, exposure to a person who has known or suspected TB infection, exposure to prisons, HIV infection, travel to or immigration from countries that have endemic infection), and exposure to respiratory irritants.

Physical examination

Vital signs, including respiratory rate, temperature, and O 2 saturation, should be noted. Signs of respiratory distress (eg, nasal flaring, intercostal retractions, cyanosis, grunting, stridor, marked anxiety) should be noted.

Head and neck examination should focus on presence and amount of nasal discharge and the condition of the nasal turbinates (pale, boggy, or inflamed). The pharynx should be checked for postnasal drip.

The cervical and supraclavicular areas should be inspected and palpated for lymphadenopathy.

Lung examination focuses on presence of stridor, wheezing, rales, rhonchi, decreased breath sounds, and signs of consolidation (eg, egophony, E to A change, dullness to percussion).

Abdominal examination should focus on presence of abdominal pain, especially in the upper quadrants (indicating possible left or right lower lobe pneumonia).

Examination of extremities should note clubbing or cyanosis of nail beds (cystic fibrosis).

Red flags

The following findings are of particular concern:

  • Cyanosis or hypoxia on pulse oximetry

  • Stridor

  • Respiratory distress

  • Toxic appearance

  • Abnormal lung examination

Interpretation of findings

Clinical findings frequently indicate a specific cause (see Some Causes of Cough in Children); the distinction between acute and chronic cough is particularly helpful although it is important to note that many disorders that cause chronic cough begin acutely and patients may present before 4 wk have passed.

Other characteristics of the cough are helpful but less specific. A barky cough suggests croup or tracheitis; it can also be characteristic of psychogenic cough or a postrespiratory tract infection cough. A staccato cough is consistent with a viral or atypical pneumonia. A paroxysmal cough is characteristic of pertussis or certain viral pneumonias (adenovirus). Failure to thrive or weight loss can occur with TB or cystic fibrosis. Nighttime cough can indicate postnasal drip or asthma. Coughing at the beginning of sleep and in the morning with waking usually indicates sinusitis; coughing in the middle of the night is more consistent with asthma. In young children with sudden cough and no fever or URI symptoms, the examiner should have a high index of suspicion for foreign body aspiration.

Testing

Children with red flag findings should have pulse oximetry and chest x-ray. All children with chronic cough require a chest x-ray.

Children with stridor, drooling, fever, and marked anxiety need to be evaluated for epiglottitis, typically in the operating room by an ENT specialist prepared to immediately place an endotracheal or tracheostomy tube. If foreign body aspiration is suspected, chest x-ray with inspiratory and expiratory views should be done.

Children with TB risk factors or weight loss should have a chest x-ray and PPD testing for TB.

Children with repeated episodes of pneumonia, poor growth, or foul-smelling stools should have a chest x-ray and sweat testing for cystic fibrosis.

Acute cough in children with URI symptoms and no red flag findings is usually caused by a viral infection, and testing is rarely indicated. Many other children without red flag findings have a presumptive diagnosis after the history and physical examination. Testing is not necessary in such cases; however, if empiric treatment has been instituted and has not been successful, testing may be necessary. For example, if allergic sinusitis is suspected and treated with an antihistamine that does not alleviate symptoms, a head CT may be necessary for further evaluation. Suspected GERD unsuccessfully treated with an H 2 blocker and/or proton pump inhibitor may require evaluation with a pH or impedance probe study or endoscopy.

Treatment

Treatment is management of the underlying disorder. For example, antibiotics should be given for bacterial pneumonia; bronchodilators and anti-inflammatory drugs should be given for asthma. Children with viral infections should receive supportive care, including O 2 and/or bronchodilators as needed.

Little evidence exists to support the use of cough suppressants and mucolytic agents. Coughing is an important mechanism for clearing secretions from the airways and can assist in recovery from respiratory infections. Use of nonspecific drugs for cough suppression is discouraged in children.

Key Points

  • Clinical diagnosis is often adequate.

  • A high index of suspicion for foreign body aspiration is needed if children are age 6 mo to 6 yr.

  • Antitussives and expectorants lack proof of effect in most cases.

  • Obtain a chest x-ray if patients have red flag findings or chronic cough.

Resources In This Article

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