Cough in Children: A Merck Manual of Patient Symptoms podcast
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.
Causes of cough differ depending on whether the symptoms are acute (< 4 wk) or chronic (see Table 3: Some Causes of Cough in Children).
For acute cough, the most common cause is
For chronic cough, the most common causes are
Foreign body aspiration and diseases such as cystic fibrosis and primary ciliary dyskinesia are less common, although they can all result in persistent cough.
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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.
Vital signs, including respiratory rate, temperature, and O2 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).
The following findings are of particular concern:
Interpretation of findings:
Clinical findings frequently indicate a specific cause (see Table 3: 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.
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 H2 blocker and/or proton pump inhibitor may require evaluation with a pH or impedance probe study or endoscopy.
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 O2 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.
Last full review/revision August 2013 by Deborah M. Consolini, MD
Content last modified October 2013