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Fifteen-minute consultation: A structured approach to the management of chronic cough in a child
  1. Cherry Alviani1,
  2. Gary Ruiz1,
  3. Atul Gupta1,2
  1. 1 Department of Paediatric Respiratory Medicine, King’s College Hospital, London, UK
  2. 2 Paediatric Respiratory Medicine, King’s College London, London, UK
  1. Correspondence to Dr Atul Gupta, Department of Paediatric Respiratory Medicine, King’s College Hospital, Denmark Hill, London SE5 9RS, UK; atul.gupta{at}kcl.ac.uk

Abstract

Coughing is a primary pulmonary defence mechanism that enhances clearance of secretions and particles from the airways and protects against aspiration of foreign materials. Coughing may affect 30% of children at any given time (1). Many are healthy children but some may have serious underlying disease. Childhood cough accounts for a large number of consultations and 80% of families who are referred to a paediatric respiratory clinic for chronic cough have sought medical advice five times or more (2). The majority of childhood coughs are secondary to an acute respiratory tract infection and will improve once the infection resolves, usually within 1 to 3 weeks. With pre-school children who may experience between 6 and 10 respiratory infections a year differentiating acute recurrent cough from chronic cough is key (Table 1). Chronic cough can significantly impact a family’s quality of life, as it affects the child’s sleep, school attendance and play. Parents experience distress and anxiety, worrying that the cough may lead to long-term chest damage or even death (3). This article aims to guide clinicians through the assessment of the child with a chronic cough. It will discuss identifying causes, use of first line investigations, initiating appropriate management and addressing parental anxiety and exacerbating factors (4,5).

  • Cough
  • Children
  • Chronic

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Coughing is a primary pulmonary defence mechanism that enhances clearance of secretions and particles from the airways and protects against aspiration of foreign materials. Coughing may affect 30% of children at any given time.1 Many are healthy children, but some may have serious underlying disease. Childhood cough accounts for a large number of consultations, and 80% of families who are referred to a paediatric respiratory clinic for chronic cough have sought medical advice five times or more.2 The majority of childhood coughs are secondary to an acute respiratory tract infection and will improve once the infection resolves, usually within 1 to 3 weeks. With preschool children who may experience between 6 and 10 respiratory infections a year, differentiating acute recurrent cough from chronic cough is key (table 1). Chronic cough can significantly impact a family’s quality of life, as it affects the child’s sleep, school attendance and play. Parents experience distress and anxiety, worrying that the cough may lead to long-term chest damage or even death.3

Table 1

Cough definitions4 5 18

This article aims to guide clinicians through the assessment of the child with a chronic cough. It will discuss identifying causes, use of first-line investigations, initiating appropriate management and addressing parental anxiety and exacerbating factors.4 5 Chronic cough usually falls into these five broad aetiological categories:

  • Normal child

  • Serious underlying illness, for example, cystic fibrosis or tuberculosis

  • Minor problem, for example, upper airway cough syndrome

  • ‘Asthma syndrome’

  • Psychogenic cough

History and examination

All medical consultations should commence with a detailed history and examination. This may immediately identify a ‘specific cough’ due to an underlying condition (box 1).

Box 1

Conditions causing chronic cough.4 5

Infections:

  • Viral respiratory tract infections

  • Postinfectious illness (including Mycoplasma, pertussis and chlamydia)

  • Tuberculosis

Atopic conditions:

  • Asthma

  • Allergic rhinitis

Chronic suppurative lung disease:

  • Cystic fibrosis

  • Primary ciliary dyskinaesia

  • Immune deficiencies

  • Other causes of bronchiectasis

  • Protracted bacterial bronchitis

Inhaled foreign body

Airway lesions:

  • Compression, for example lymph nodes, vascular ring

  • Airway malacia

Upper airway disease:

  • Upper airway cough syndrome (formerly known as postnasal drip syndrome)

  • Adenotonsillar hypertrophy

  • Rhinosinusitis or rhinitis

  • Nasal polyps

Recurrent aspiration (from oesophageal or swallowing problems):

  • Gastro-oesophageal reflux disease (GORD)

  • Neuromuscular disease

  • Tracheo-oesophageal fistula

Interstitial lung disease

Other:

  • Environmental exposure to tobacco smoke or other chemical irritants

  • Psychogenic cough

  • Cardiac disease

  • Medication related (e.g. ACE inhibitors)

A specific cough history would focus on:

  • Age of onset and duration

  • Its nature (wet or dry)

  • Its quality (eg, barking, wheezing or honking)

  • Alleviating and triggering factors

  • Associated symptoms

  • Exposure to smoking or other aero-irritants

  • Response to prior therapy—focusing on bronchodilators

  • Disappearance when sleeping

  • Differentiating between recurrent acute and chronic cough

Certain children (box 2) are likely to have an ineffective cough placing them at higher risk of recurrent pneumonia and chronic airway disease from aspiration and retention of secretions.

Box 2

Conditions associated with ineffective cough

  • Neuromuscular disease

  • Chest wall deformities

  • Children with reduced function of the abdominal wall musculature

  • Tracheo-bronchomalacia (‘floppy’ airways) or obstructive airway diseases

  • Laryngeal disorders

  • Tracheostomy

In addition to a thorough respiratory assessment, particular attention should also be given to the cardiovascular and ear nose throat (ENT) examinations and to growth. Ideally, the cough should be witnessed in clinic, and thus if it does not occur spontaneously during the consultation, a voluntary cough manoeuvre ought to be performed.

This initial assessment may suggest one of the conditions and exclude others listed in box 1. Some important clinical features, which can indicate a specific cause of the chronic cough, are listed in table 2. It is important to distinguish a wet or dry cough. A chronic wet cough and an abnormal respiratory examination are strongly suggestive of underlying disease.6 Parental reporting of whether a cough is wet or dry is usually accurate and correlates with investigation findings7 as opposed to their report of cough severity or frequency, which is more closely related to the amount of sleep disturbance caused.8

Table 2

Possible diagnosis and specific investigations to be considered

Investigations

Investigations in the child with chronic cough will be directed by the initial assessment. If clinical features are found that suggest a specific diagnosis, then the appropriate investigations should be arranged (box 2). A detailed discussion of all possible investigations is outside the scope of this article.

Even in the absence of any concerning features on history and examination, a chest X-ray (CXR), spirometry (if available), sputum culture and serology are appropriate initial investigations for most children presenting with chronic cough.

Chest X-ray

An abnormality on CXR is strongly suggestive of underlying pathology6 and should direct further investigations. A definitive diagnosis is rarely made on the CXR alone, but it can lend support to specific diagnoses and help determine need for subsequent tests.

Spirometry

Spirometry should be attempted in children old enough to perform it. This would include forced vital capacity, forced expiratory volume in 1 second before and after administering a short-acting β2-agonist, and forced mid-expiratory flow. These measurements can have diagnostic utility by determining the presence and severity of respiratory obstruction and restriction as well as bronchodilator reversibility.

Laboratory investigations

For children with a chronic wet cough, obtaining a sputum sample for microbiological assessment is ideal. This can be challenging in young children,4 and in this group, a cough swab will often suffice.

Specific laboratory investigations for Bordetella pertussis and Mycoplasma pneumoniae are indicated when there is a suggestion of a pertussis-like syndrome. Pertussis is often underdiagnosed. The classical picture may be altered by use of antibiotics and vaccination. In a recent study, 20% of school-age children with a persistent cough had serological evidence of recent pertussis infection despite being immunised.9

Management

After a thorough initial assessment and investigations, an underlying diagnosis may be obvious, which can then direct appropriate management. The management of each of these conditions is beyond the scope of this article. However, a more common and more challenging scenario is that of a child with a chronic cough, normal CXR (and spirometry) and no clinical pointers of underlying disease, whose parents are anxious for treatment and resolution of the cough. In these cases, the nature of the cough (ie, whether dry or wet) is the most important diagnostic clue as there are distinct management algorithms. A suggested algorithm is shown in figure 1.

Figure 1

Suggested algorithm for the investigation and management of children with non-specific chronic cough—modified from Chang et al.19 CXR, chest X-ray; ICS, inhaled corticosteroid.

Dry cough

In otherwise well children, the use of a ‘watchful waiting’ approach is appropriate4 as up to 70% will improve spontaneously.10 Parental anxieties and expectations should be addressed, and use of over-the-counter cough medications discouraged.11 Exposure to aero-irritants such as tobacco smoke should be minimised and smoking cessation advice given to parents and relatives who subject the child to secondhand tobacco smoke.

The history should be reviewed again, with a focus on excluding the possibility of a choking episode or underlying rhinitis/sinusitis. A history strongly suggestive of choking should result in a referral for bronchoscopy even with a normal examination and CXR. Empirical treatment of possible GORD-related cough with proton-pump inhibitors is not recommended, as they do not improve the cough and are associated with an increase in respiratory infections.12

A trial of inhaled corticosteroid (ICS) can be considered, in particular in children with a history of previous chronic cough and atopic sensitisation.10 Guidelines recommend an 8-week treatment with an adequate dose, eg, beclometasone 200 µg twice daily, followed by stopping the medication and reassessment.4 5 It is important to remember that a high proportion of these children would have improved spontaneously irrespective of treatment, thus an initial response to ICS may be misleading (the so called ‘period effect’5 10). Diagnosis of an ‘asthma syndrome’ is suggested by recurrence of the cough once ICS are stopped.

Wet cough

Children with a chronic wet cough, but no other concerning features, may have protracted bacterial bronchitis (PBB).

Protracted bacterial bronchitis

PBB, caused by chronic infection of the conducting airways, remains under-recognised and undertreated by healthcare professionals, perhaps because of reluctance to use a prolonged course of antibiotics in well children.13 In studies of children with chronic cough, PBB was found to account for up to 40% of cases,6 14 with the highest incidence in the preschool age group.

PBB is a clinical diagnosis made in the presence of a chronic wet cough (lasting 4 weeks or more) that responds to treatment with antibiotics, in the absence of other underlying pathology.13 Antibiotics act by eradicating the bacterial biofilm,15 and a 2-week to 3-week course of a broad-spectrum antibiotic such as co-amoxiclav is an appropriate first-line management, as Haemophilus influenzae and Streptococcus pneumoniae are the main causative organisms.14–16 Antibiotics have been shown to significantly improve resolution of the cough.15 This should be followed by review and possibly a second antibiotic course if the cough persists.

Children who fail to respond to two courses of antibiotics should be referred to a paediatric respiratory specialist for further investigations of possible underlying serious causes.15

Conclusion

Chronic cough in childhood is common, a significant source of parental anxiety and a potential indicator of serious underlying disease. Early management is also important for future pulmonary health, for example, prevention of progression to bronchiectasis in PBB. Assessment should involve a detailed history and examination, with a focus on the identification of specific cough pointers that may direct further investigations. Early referral and use of a clinical algorithm for the management of chronic cough in children is associated with increased cough resolution and improved quality of life.17 We therefore suggest a management algorithm for children with chronic cough (figure 1).

Acknowledgments

The authors thank Dr Theo Fenton and Dr Edward Holloway for their advice on the manuscript.

References

Footnotes

  • Contributors CA drafted the initial draft. GR and AG reviewed the initial draft and wrote the subsequent draft.

  • Competing interests None declared.

  • Provenance and peer review Commissioned; externally peer reviewed.