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

## Overview[edit | edit source]

Cough is a common complaint of the pediatric population of the outpatient department. It is a natural reflex by which foreign and infectious particles are cleared through an involuntary expulsive force of air by the dynamic mechanism of respiratory airways. The word 'Cough' is derived from the 14th century Dutch word 'Kochen' and the high middle German word 'Kuchen'. Cough is classified under several categories. For example, duration of the complaint, nature or quality, anatomical location, etiology and grades of coughs. Stimulation to cough receptors provokes sensations of coughing through the afferent pathway via the vagus nerve, central respiratory centers in the upper pons and medulla, and efferent pathways via the phrenic and vagus branches. Differential diagnoses of cough are evaluated through identifying specific etiology, presenting symptoms, detailed history and findings of physical examination, laboratory, and imaging investigations. Some of the causes are emergently managed to reduce the mortality of a child.The mainstay of therapy for cough is supportive. Antihistamine, antitussive medications and nasal decongestant are provided for alleviating symptoms of acute cough. Allergic conditions are treated with steroids.

## Historical Perspective[edit | edit source]

* The word cough was first derived from the middle English word '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[edit | edit source]

* Cough in children may be classified or defined according to the duration of presenting complaints, quality and sound, and causes of cough into several groups.[1]:
* 1 Duration of Presenting complaints: According to the duration of cough, it can be sub-classified into three categories:
* Acute: < 3 weeks.
* Subacute: 3 to 8 weeks.
* Chronic: > 8 weeks.

* 2\. Nature or quality and sounds: According to the quality and sound, the 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 the causes, a cough is subdivided into following three subgroups:
* Specific cough.
* Nonspecific cough.
* Expected cough or Normal cough.

* 4\. Anatomic classification on the causes of a cough: A 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:[2]
* 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-infectious categories broadly.

## Pathophysiology[edit | edit source]

* A cough is a natural innate primitive reflex that helps in mucocilliary clearance of foreign particles and secretions from respiratory tracts. It is also a defense mechanism protecting the respiratory airways from aspiration of pathogens, particulates and secretions. A complex arc comprised of neuro-respiratory pathways helps in initiating the cough reflex.[3]

| Mechanical and chemical stimulation of cough receptors (RARs or Rapidly adapting receptors, C fibers or slowly adapting receptors) in Respiratory airways|

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| 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 cells are characteristic findings of sputum produced by coughing.

## Causes[edit | edit source]

Causes of cough in children according to duration[4][5][6]:

| Cough|

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| Acute(<3 weeks) •Common Cold
•Allergic Rhinitis
•Bronchitis
•Bronchiolitis
•Asthma
•Whooping Cough
•Influenza
•Croup or Tracheolaryngobronchitis
•Pneumonia
•Irritation by smoking
•Foreign Body
•GERD|

| Subacute(3-8 weeks) •Whooping Cough or Pertussis
•Post infectious Cough
•Bacterial Sinusitis
•Asthma|

| Chronic(>8 weeks) •Upper Airway Cough Syndrome
•Asthma
•Bronchiectasis in Cystic fibrosis and Kartagener Syndrome
•Chronic sinusitis
•Malacia
•Foreign Body
•Nonasthmatic eosinophilic bronchitis
•Respiratory environmental toxins

According to quality and sound of cough in children, the causes can be classified according to the following chart:

| Dry or Hacking or Nonproductive|

| Sinusitis, Tonsillitis, Pharyngitis, Allergic Rhinitis, GERD, Asthma, Environmental exposure to irritants(pollen, dust, mites, smoke), Post infectious cough.|

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| 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)|

| Stridor|

| Viral Croup, Epiglottis, Bacterial tracheitis, Retropharyngeal and peritonsilar abscess|

| Burning cough|

| Bacterial Bronchitis, Irritants|

Based on anatomical location the causes of cough in children can be demonstrated in the following chart:

| Nose and Paranasal sinuses|

| Rhinitis, Foreign Body, Sinusitis, Nasal polyp, ppHypertrophied inferior turbinate]]|

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| 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, Myocarditis, Heart failure, Cardiomyopathies, Wegener granulomatosis, Valvular heart disease, Vasculitis, Arteriovenous malformation|

| External ear and Tympanic membrane|

| Otitis media and externa, Impaction of foreign body, wax, Myringitis|

| Esophagus|

| GERD, Tracheoesophageal Fistula|

## Differentiating Cough from other Diseases[edit | edit source]

Organ system  | Diseases  | Clinical manifestations  | Diagnosis  | Other features

|
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Symptoms  | Physical exam
Onset  | Duration  | Productive cough  | Hemoptysis  | Weight loss  | Fever  | Dyspnea  | Physical Examination  | Lab findings  | Imaging  | PFT  | Gold standard
Respiratory | Upper airway diseases | Epiglottitis[7][8] | Abrupt or acute  |

* 12−24 hours

| −  | −  | −  | \+  | \+  |

* Ill appearing child in Tripod posture
* Inspiratory Stridor
* Hoarseness / Hot-potatoes or Muffled voice
* Drooling, Tachypnea, Tachycardia
* Cervical lymphadenopathy, Erythematous pharynx and larynx

* Elevated white blood count in CBC
* Blood culture may show bacterial growth
* Epiglottal culture in intubated patients may show bacterial growth

* Enlarge epiglottis (>8 mm), loss of vallecular air space and distended hypopharynx as known as 'Thumb print' sign on lateral neck X−ray may be helpful

* Normal function

* Direct visualization of erythematous and edematous epiglottis

* Tripod posture
* Drooling
* Tenderness of the anterior part of the neck
* Etiology: Haemophilus influenzae

Croup[9] | Acute  |

* 3−5 days

| \+  | −  | −  | \+  | \+  |

* Stridor
* Crackles

* Leukopenia

* Subglottic narrowing (steeple sign) in postero−anterior radiograph chest

* Decreased tidal volume

* Clinical diagnosis.
* Laboratory findings and imaging are not necessary for diagnosis

* Barking cough
* Etiology: Parainfluenza virus type 1 (most common)

Pertussis[10][11] | Acute  |

* Two weeks

| \+ Whooping sound  | −  | \+  | \+  | \+  |

* Clear chest

* Polymerase chain reaction (PCR) shows Bordetella pertussis
* Serologic testing

* Atelectasis may seen on chest imaging
* Lymphadenopathy

* Normal function

* Culture

* Etiology: Bordetella pertussis
* Phases: Catarrhal, paroxysmal and convalescent

Common Cold[12] | Acute  |

* 3−10 days

| \+  | −  | −  | \+  | −  |

* Rales
* Wheezing

* Bacterial culture is not indicated

* Chest X−Ray in patients with signs of consolidation

* Normal function

* Clinical diagnosis

* Conjunctival injection
* Nasal congestion

Tonsilitis[13][14][15] | Acute or Acute Recurrent, Chronic  |

* Varies

| +(Mucus from inflamed tissue)  | −/+  | −  | \+  | Odynophagia, Tachypnea  |

* Stridor
* Hoarseness of voice/ Dysphonia
* Cervical Lymphadenopathy

* Rapid Antigen Detecting Test
* Throat Swab Culture
* EBV Heterophile Antibody Test
* Monospot Test
* Complete Blood Count

* Chest X−Ray shows normal finding. USG may show Peritonsillar abscess.

* Normal function

* Rapid Antigen Detecting Test

* Etiology: Rhinovirus, Adenovirus, Respiratory Syncitial Virus, Influenza Virus, Corona Virus, Group A streptococci

Seasonal Influenza[16][17] | Acute  |

* Upper respiratory tract symptoms with fever peaking at three to four days, resolved by seven to ten days.

| −  | −  | −  | +(High grade)  | \+  |

* Fussiness, Vomiting, Diarrhea, Myalgia,
* Focal wheezing, Rales, Tachypnea, Tachycardia, Retractions, Seizures

* RT−PCR
* Virus culture
* Rapid Influenza diagnostic test
* Immunofluroscence-Direct or indirect Antibody testing

* Reticular or reticulonodular opacities in chest X−Ray

* Normal function

* Clinical diagnosis

* Etiology: A or B Influenza virus

Sinusitis[18][19] | Acute, Subacute, Chronic, recurrent  |

* Acute: < four weeks
* Subacute: four−twelve weeks
* Chronic: > twelve weeks
* Recurrent: > four episodes / acute episode of rhinosinusitis yearly.

| \+  | −  | −  | \+  | \+  |

* Restlessness, Nasal Congestion, Post Nasal Drip, Facial Pain, Rhinorrhea

* In complicated acute bacterial rhinosinusitis, endoscopic cultures or sinus aspirate is indicated
* Nasal culture may also be helpful

* Air−fluid level, mucosal edema and bony erosion of sinus on CT
* MRI for distinguish the etiology

* Normal function

* Clinical diagnosis: Nasal congestion and Post Nasal drip  , obstruction, and purulent rhinorrhea

Organ system  | Diseases  | Clinical manifestations  | Diagnosis  | Other features
Symptoms  | Physical exam
Onset  | Duration  | Productive cough  | Hemoptysis  | Weight loss  | Fever  | Dyspnea  | Physical findings  | Lab findings  | Imaging  | PFT  | Gold standard
Respiratory | Lower airway | Asthma[20][21] | Chronic  |

* Years

| \+ Clear mucoid or yellow sputum | −  | −  | −  | \+  |

* Wheezing (expiratory)
* Rales
* Rhonchi

* Eosinophilia
* Total serum IgE in test for allergy may be helpful

* Normal airways in chest X−ray
* CT if there any abnormality in chest x−ray

* FEV1/FVC ratio <70% and FEV1 >15% increase after 15 minutes of 2 puffs of beta 2 sympathomimetic drug
* After physical active FEV1 decreases by >15%
* After inhaled corticosteroid (ICS)FEV1 increased by >15%

* Airflow limitation on spirometry

* Family history
* Seasonal variation

Bacterial Protracted Bronchitis[22][23] | Chronic  |

* At least four weeks

| +(Purulent)  | −  | \+  | +/−  | \+  |

* Wheezing
* Rhonchi

* Sputum culture is not indicated
* PCR in bacterial infection may be helpful

* Chest x−ray to exclude other diseases

* FEV1 < 80%

* Clinical diagnosis

* Majority of cases are caused by Streptococci Pneumoniae, Hemophylous Influenza, Staphylococcus aureus

Bronchiectasis[24][25][26] | Chronic  |

* Months to years

| \+ Mucopurulent sputum | \+  | −  | −  | \+  |

* Crackles
* Wheezing
* Shortness of breath
* Chest Pain

* Complete blood count (CBC)
* Sweat Test, CFTR Gene analysis
* Ciliary motility test, Nitric Oxide Test, Ciliary structures, Genetic Testing
* IgG, IgM and IgA
* Sputum culture for fungi, bacteria and mycobacteria

* Linear atelectasis and dilated airways in chest x−ray
* Bronchoscopy, Upper GI Endoscopy, MRI/CT will provide information of other etiologies.

* FEV1/FVC <70%
* Normal FVC
* Low levels of FEV1

* CT of chest

* Digital clubbing
* Recurrent pleurisy

'Foreign body aspiration[27][28][29] | Acute  |

* Sudden Onset

| \+  | +/-  | −  | +/-  | \+  |

* Wheezing, Inspiratory or Biphasic Strioor
* Unilateral Decreased breath sounds
* Cyanosis

* No specific tests

* Hyperinflated lungs, atelectasis, and mediastinitis
* Shift in chest radiograph when the object is radio−opaque
* CT may be helpful

* Not specific

* Bronchoscopy

* In children <1 year
* Organic materials in children

Bronchiolitis[30][31] | Acute  |

* 8−15 days

| \+  | −  | −  | \+  | \+  |

* Rhinorrhoea
* Cyanosis, Hypoxia
* Intercostal and subcostal retraction
* Tachypnea
* Wheezing
* Crackles
* Grunting and Nasal Flaring

* Complete blood count (CBC) may be helpful
* Urinalysis & urine culture ( in infants)

* Chest x−ray may be helpful

* Normal function or obstructive changes (FEV1/FVC <70%)
* Air trapped in Lungs
* Decreased Diffusing capacity of Carbon Monoxide ( DLCO)

* Clinical diagnosis

* Etiology: Respiratory syncytial virus, Rhinovirus
* Children <2 years

Organ system  | Diseases  | Clinical manifestations  | Diagnosis  | Other features
Symptoms  | Physical exam
Onset  | Duration  | Productive cough  | Hemoptysis  | Weight loss  | Fever  | Dyspnea  | Physical Examination  | Lab findings  | Imaging  | PFT  | Gold standard
Respiratory | Lung Parenchyma | Pneumonia[32][33][34] | Acute  |  | \+  | −  | −  | \+  | \+  |

* Crackles
* Egophony
* Decreased bronchial sounds, Rhonchi
* Rapid Breathing
* Intercostal retractions
* Nasal Flaring, Grunting
* Tachypnea, Tachycardia
* Vomiting

* Leftward shift leukocytosis
* Blood culture in hospitalized patients
* Sputum culture in hospitalized patients

* Consolidation, cavitation, and infiltrated interstitial in chest x−ray
* Anatomical changes observed in chest CT

* Not specific

* Infiltration observed in chest x−ray

* Community−acquired pneumonia
* Healthcare−associated pneumonia

Tuberculosis (TB)[35] | Chronic[36] |

* Weeks to months

| \+  | \+  | \+  | \+  | \+  |

* Pleural effusion
* Crackles
* Whispered pectoriloquy
* Decreased fremitus
* Rhonchi

* Sputum AFB stain may be +.
* Mycobacterium Tuberculosis culture may be +
* Molecular testing may be helpful

* Reactivation of TB is observed as infiltration in the upper lobe in chest x−ray

* Decreased FEV1
* Reduced FVC

* Isolation of Mycobacterium tuberculosis

* Etiology: Mycobacterium tuberculosis

Organ system  | Diseases  | Clinical manifestations  | Diagnosis  | Other features
Symptoms  | Physical exam
Onset  | Duration  | Productive cough  | Hemoptysis  | Weight loss  | Fever  | Dyspnea  | Physical Examination  | Lab findings  | Imaging  | PFT  | Gold standard
Cardiac | Cardiac Failure[37][38] | Acute  |

* Hours

| −  | −  | \+  | −  | \+  |

* Crackles
* Increased respiratory rate, retraction
* Wheezing, Grunting, Nasal flaring
* JVD
* Displacement of apex beat
* Gallop rhythm, Murmur may present.
* Hepatomegaly, Ascites

| The following investigations may be helpful:

* Arterial blood gas
* BUN
* Serum creatinin
* Serum troponin
* Electrolytes
* Lactic acid
* Complete blood count

* Cardiomegaly, interstitial edema, alveolar edema, Pleural effusion and blood redistribution in lower lobes in chest x−ray

* Not specific

* Clinical diagnosis
* Tests are supportive

* 12−lead ECG
* Plasma BNP and NT−proBNP
* Echocardiography

Congenital Heart Disease | Acute or Chronic  |

* Variable

| \+  | \+  | −  | −  | \+  |

* Crackles
* Hoarseness

* Not specific

* Electrocardiogram may be helpful
* Enlargement of left atrium and appendage in chest radiograph

* FVC reduced

* Resting transthoracic echocardiography

* Stress testing
* Cardiac catheterization

Organ system  | Diseases  | Clinical manifestations  | Diagnosis  | Other features
Symptoms  | Physical exam
Onset  | Duration  | Productive cough  | Hemoptysis  | Weight loss  | Fever  | Dyspnea  | Physical Examination  | Lab findings  | Imaging  | PFT  | Gold standard
Gastrointestinal | Gastroesophageal reflux[39][40] | Chronic  |

* Variable

| \+  | −  | \+  | −  | \+  |

* Wheezing
* Hoarseness
* Regurgitation, Vomiting
* Back Arching, crying

*Apnea

* Epigastric pain

* Not specific

* Upper endoscopy may be helpful
* Barium esophagram may be helpful

* Normal function

* PH testing

| −−

## Epidemiology and Demographics[edit | edit source]

* A cough is one of the most common presenting symptoms of children in the outpatient department.
* Ninety percent of acute coughs in children are resolved within three weeks. The prevalence of chronic cough in children is approximately 5% to 10% in the USA according to the American Academy of Pediatrics.

### Age[edit | edit source]

* Cough is more commonly observed among children under 5 years of age.[41]

### Gender[edit | edit source]

* Boys are more commonly affected with cough than girls.[42]

### Race[edit | edit source]

* There are racial predispositions for certain causes of cough in children. Asthma is predominant in Blacks and American Indians or Alaska natives while Cystic fibrosis, Wegener's granulomatosis more frequently affect Caucasians according to the American Lung Association.

## Risk Factors[edit | edit source]

* Common risk factors in the development of a cough in children are:[43][44]
* 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[edit | edit source]

* The majority of patients with acute cough have recovery within three weeks in 90% of cases. Some cases are progressed to subacute 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.[45]
* 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, and a choking sensation(foreign body impaction).[46]
* If left untreated, acute cough can cause following the complications in children:[4][45]
* Otitis Media
* Rash
* Vomiting
* Diarrhea
* Bronchitis
* Pneumonia
* Chronic cough can progress to[47]\-
* Inability to sleep
* Bronchospasm
* Dizziness/ Syncope
* Pneumothorax
* Pneumomediastinum
* Rib fracture

* Prognosis is generally excellent and efficiently treatable in most of the etiology of cough in children.

## Diagnosis[edit | edit source]

### Diagnostic Criteria[edit | edit source]

* Diagnosis of causes of a cough is made after a detailed history, presenting complaints and physical examination and laboratory findings in some cases. Cough can be classified according to:[48]
* 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, alleviating factors, amount of work to breathe, 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 choking, household socioeconomic status, family history, vaccination history, drug abuse and smoking in family members, atopy, antenatal, perinatal, postnatal, birth history, developmental history, feeding history.

The following signs are alarming which need further emergent evaluation by the physician:

* Cyanosis or hypoxemia or hypoxia
* Respiratory distress
* Stridor
* Toxic appearance
* Weight loss

### Symptoms[edit | edit source]

* Cough may be associated with the following depending upon the cause:

* Breathlessness and episodes of coughing
* Sneezing
* Fever
* Sore Throat
* Night Sweats
* Arching Back
* Irritability
* Failure to thrive
* Fussiness
* Choking sensation(Foreign body impaction)
* Chills and Rigor
* Wheezing
* Headache, myalgia, fatigue

### Physical Examination[edit | edit source]

* Patients with cough are usually restless, irritable, fussy. Children with severe respiratory distress usually are toxic and cyanotic in appearance. Presence of grunting, nasal flaring, intercostal or subcostal retraction or accessory muscle usage needs prompt evaluation.[46][48]
* Physical examination may be remarkable for:

* Vital signs: Documentation according to patient's age
* Blood pressure
* Temperature
* Respiratory rate
* Heart rate

*     * Growth charts and developmental milestones: weight, height, length, occipitofrontal circumference
* General Appearance: Level of consciousness, Cyanosis, Distressed or ill-appearing, hydration and nutritional status.
* Skin: Turgor, color, texture, rashes or any other abnormal findings.
* Lymphatics: Lymphadenopathy, location, number and size, consistency, adherence to underlying structures.
* Head: Size, shape, fontanelle, overlapping suture, scalp, hair.
* Eyes: Lacrimation, redness, irritation, conjunctival injection, periorbital redness.
* Ears: Position of ears along with external auditory canal, tympanic membrane visualization.
* Nose: Any deviation of nasal septum, normal or hypertrophied inferior turbinate, nasal polyps and congestion, nasal discharge, tenderness over sinus point.
* Mouth and throat: Look for any associated abnormality
* Lips: Color, mucosal abnormality and congenital lesions.
* Buccal mucosa: Hydration, Color, Presence of anomaly.
* Tongue and teeth and gum: Developmental anomaly, Color, papillae.
* Palate: Anomaly, arch.
* Tonsils: Color, size, any membrane, calcification and exudates.
* Posterior pharyngeal wall: Color, appearance.
* Gag reflex: Intact or not.
* Neck: Thyroid, trachea position and examination, any cystic or nodular masses, presence of nuchal rigidity.
* Respiratory:
* Inspection: Breathing pattern (abdominal and periodic), respiratory rate, accessory muscle usage, chest wall shape.
* Auscultation: breath sound symmetry, vesicular, bronchial, rales, rhonchi, wheezes, stridor.
* Percussion: resonance, hyper resonance and dull.
* Palpation: trachea position, tactile fremitus.
* Cardiovascular: rhythm, murmur, any radiation of sound, pulse in both extremities.
* Gastrointestinal: Shape of abdomen, Umbilicus, Bowel sounds, Palpation to evaluate any organomegaly or masses or rebound guarding.
* Musculoskeletal: Aching back, scoliosis, lordosis, kyphoscoliosis, swelling and tenderness in any muscles, joint, clubbing, edema, deformity of extremities, gait and posture, any sign for hip dysplasia.
* CNS: Primitive reflex, superficial and deep tendon reflex, strength and tone of muscles, cranial nerve examination.
* Genitourinary: Presence of external genitalia deformity , hydrocele, cryptorchidism or hernia.

### Laboratory Findings[edit | edit source]

* There are no specific laboratory findings associated with cough. Laboratory tests are done to differentiate the causes of cough in children[47].
* Complete Blood Count
* Arterial blood gas analysis
* Culture of nasopharyngeal swab and broncho alveolar lavage
* Gross and microscopic analysis and culture of sputum
* AFB testing and tuberculosis screening
* Allergy test
* Serum Immunoglobulins, autoantibodies
* Sweat test
* Exhaled nitric oxide test
* Esophageal pH
* Serology for Pertusis, CMV, Chlamydia, HIV.

### Electrocardiogram[edit | edit source]

An ECG may not be helpful in the diagnosis of congenital heart disease, myocarditis, valvular heart disease, in children.

### X-ray[edit | edit source]

Anterior/posterior view, lateral Chest and neck x-ray may be helpful in the diagnosis of causes of cough in children for: Pneumonia, Croup, Bronchitis, Epiglottitis, Foreign body impaction etc. X-ray of paranasal sinuses helps in diagnosis of sinusitis, deviated nasal septum.

### Echocardiography or Ultrasound[edit | edit source]

Echocardiography/ultrasound may be helpful in the diagnosis of causes of cough in children. Echocardiographic findings aide in the diagnosis of congenital heart disease, whereas USG findings can help in evaluating complications like peritonsillar abscess, retropharyngeal abscess promptly.

### CT scan[edit | edit source]

The High resolution CT is used for diagnosing causes of chronic cough in children such as bronchiectasis. Sometimes it helps in identifying congenital heart and lung anomalies.

### MRI[edit | edit source]

A Chest MRI may be helpful in the diagnosis of the dynamic function of airways disease.[49]. MRI can provide detailed findings of perfusion, ventilation mechanism of lungs and diaphragm. It can show oxygen enhancement, congenital anomalies too.

### Other Imaging Findings[edit | edit source]

Other imaging techniques are used to evaluate causes of cough in children.

* Flexible Bronchoscopy
* Barium esophagram.
* Angiography

### Other Diagnostic Studies[edit | edit source]

Other investigations done to rule out differential diagnosis of cough in children are:

* Spirometry for evaluating pulmonary function test.
* Bronchodilator provocation test.
* Ciliary function test.
* Genetic analysis for CFTR mutation, Primary ciliary dyskinesia etc.
* Video fluoroscopic or endoscopic swallow evaluation.
* Environmental assessment.

## Treatment[edit | edit source]

### Medical Therapy[edit | edit source]

* The mainstay of therapy for cough is supportive. Management of acute and chronic cough in children can be provided in the following sequences:[1][50][51][52]
* Identification of etiology of cough and emergently manage the emergency condition such as foreign body impaction, severe respiratory distress, apnea with maintenance of airways, breathing, circulation.
* General measures with adequate hydration, nasal airway clearance with normal saline, reducing fever with antipyretics are done to give comfort to the child.
* Medical management:
* Antihistamine, antitussive medications and nasal decongestant are provided for alleviating symptoms of acute cough. Allergic conditions are treated with steroids.
* Bronchodilators (Ipratropium bromide, Albuterol, Salmeterol, Salbutamol), Antibiotic (Amoxicillin/Clavulanate, Cephalosporins, Respiratory fluoroquinolones, Antiviral, Antifungal, Antiparasitic) are used according to evidence-based management of particular causes of cough in children.

### Surgery[edit | edit source]

* Some surgical procedures are performed for patients with Tonsillitis, adenoid hypertrophy, severe cases of laryngomalacia, tracheoesophageal fistula, congenital heart disease, complications of any disease or trauma in ear, nose, sinuses, pharynx, larynx, trachea, bronchus, lungs, and ribs.

### Prevention[edit | edit source]

* Effective measures for the primary prevention of cough include:
* Caregivers should be given health education on pros and cons of vaccination, alarming features of cough.
* Physical hygiene including airways of an infant or a child should be maintained to prevent complications.
* Head should be raised to prevent irritations in throat.
* Humidified air will help clearing the sputum easily.
* Adequate hydration to prevent formation of dry sputum.
* Avoidance of triggers in case of atopic patient.
* Nutritional balance should be maintained for rebooting the immunity.

## References[edit | edit source]

1. ↑ 1.0 1.1 Alsubaie H, Al-Shamrani A, Alharbi AS, Alhaider S (March 2015). "Clinical practice guidelines: Approach to cough in children: The official statement endorsed by the Saudi Pediatric Pulmonology Association (SPPA)". Int J Pediatr Adolesc Med. 2 (1): 38–43. doi:10.1016/j.ijpam.2015.03.001. PMID 30805435.
2. ↑ Chung KF, Bolser D, Davenport P, Fontana G, Morice A, Widdicombe J (April 2009). "Semantics and types of cough". Pulm Pharmacol Ther. 22 (2): 139–42. doi:10.1016/j.pupt.2008.12.008. PMID 19136069.
3. ↑ Polverino M, Polverino F, Fasolino M, Andò F, Alfieri A, De Blasio F (June 2012). "Anatomy and neuro-pathophysiology of the cough reflex arc". Multidiscip Respir Med. 7 (1): 5. doi:10.1186/2049-6958-7-5. PMID 22958367.
4. ↑ 4.0 4.1 "Acute cough in children".
5. ↑ Kwon NH, Oh MJ, Min TH, Lee BJ, Choi DC (May 2006). "Causes and clinical features of subacute cough". Chest. 129 (5): 1142–7. doi:10.1378/chest.129.5.1142. PMID 16685003.
6. ↑ Bergamini M, Kantar A, Cutrera R, Interest Group I (2017). "Analysis of the Literature on Chronic Cough in Children". Open Respir Med J. 11: 1–9. doi:10.2174/1874306401711010001. PMID 28553418. Vancouver style error: initials (help)
7. ↑ Abdallah C (July 2012). "Acute epiglottitis: Trends, diagnosis and management". Saudi J Anaesth. 6 (3): 279–81. doi:10.4103/1658-354X.101222. PMC 3498669. PMID 23162404.
8. ↑ "Epiglottitis, Acute Laryngitis, and Croup".
9. ↑ Cherry, James D. (2008). "Croup". New England Journal of Medicine. 358 (4): 384–391. doi:10.1056/NEJMcp072022. ISSN 0028-4793.
10. ↑ Bellamy EA, Johnston ID, Wilson AG (1987). "The chest radiograph in whooping cough". Clin Radiol. 38 (1): 39–43. PMID 3816065.
11. ↑ "Pertussis | Whooping Cough | Clinical | Information | CDC".
12. ↑ Eccles R (2005). "Understanding the symptoms of the common cold and influenza". Lancet Infect Dis. 5 (11): 718–25. doi:10.1016/S1473-3099(05)70270-X. PMID 16253889.
13. ↑ Stelter K (2014). "Tonsillitis and sore throat in children". GMS Curr Top Otorhinolaryngol Head Neck Surg. 13: Doc07. doi:10.3205/cto000110. PMC 4273168. PMID 25587367.
14. ↑ Bartlett A, Bola S, Williams R (2015). "Acute tonsillitis and its complications: an overview". J R Nav Med Serv. 101 (1): 69–73. PMID 26292396.
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16. ↑ Kumar V (February 2017). "Influenza in Children". Indian J Pediatr. 84 (2): 139–143. doi:10.1007/s12098-016-2232-x. PMID 27641976.
17. ↑ Kondrich J, Rosenthal M (June 2017). "Influenza in children". Curr Opin Pediatr. 29 (3): 297–302. doi:10.1097/MOP.0000000000000495. PMID 28346272.
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19. ↑ Shahid SK (2012). "Rhinosinusitis in children". ISRN Otolaryngol. 2012: 851831. doi:10.5402/2012/851831. PMC 3671714. PMID 23762621.
20. ↑ Gelfand EW (May 2009). "Pediatric asthma: a different disease". Proc Am Thorac Soc. 6 (3): 278–82. doi:10.1513/pats.200808-090RM. PMC 2677403. PMID 19387030.
21. ↑ van Aalderen WM (2012). "Childhood asthma: diagnosis and treatment". Scientifica (Cairo). 2012: 674204. doi:10.6064/2012/674204. PMC 3820621. PMID 24278725.
22. ↑ Zhang XB, Wu X, Nong GM (March 2020). "Update on protracted bacterial bronchitis in children". Ital J Pediatr. 46 (1): 38. doi:10.1186/s13052-020-0802-z. PMC 7106696 Check `|pmc=` value (help). PMID 32228653 Check `|pmid=` value (help).
23. ↑ "www.thoracic.org" (PDF).
24. ↑ Pizzutto SJ, Hare KM, Upham JW (2017). "Bronchiectasis in Children: Current Concepts in Immunology and Microbiology". Front Pediatr. 5: 123. doi:10.3389/fped.2017.00123. PMC 5447051. PMID 28611970.
25. ↑ Redding GJ (February 2009). "Bronchiectasis in children". Pediatr Clin North Am. 56 (1): 157–71, xi. doi:10.1016/j.pcl.2008.10.014. PMID 19135586.
26. ↑ Bouyahia O, Essadem L, Matoussi N, Gharsallah L, Fitouri Z, Mrad Mazigh S, Boukthir S, Bellagah I, Ben Becher S, Sammoud El Gharbi A (November 2008). "Etiology and outcome of bronchiectasis in children: a study of 41 patients". Tunis Med. 86 (11): 996–9. PMID 19213492.
27. ↑ Fraga Ade M, Reis MC, Zambon MP, Toro IC, Ribeiro JD, Baracat EC (February 2008). "Foreign body aspiration in children: clinical aspects, radiological aspects and bronchoscopic treatment". J Bras Pneumol. 34 (2): 74–82. doi:10.1590/s1806-37132008000200003. PMID 18345450.
28. ↑ Aslan N, Yıldızdaş D, Özden Ö, Yöntem A, Horoz ÖÖ, Kılıç S (2019). "Evaluation of foreign body aspiration cases in our pediatric intensive care unit: Single-center experience". Turk Pediatri Ars. 54 (1): 44–48. doi:10.14744/TurkPediatriArs.2019.60251. PMC 6559979 Check `|pmc=` value (help). PMID 31217709.
29. ↑ Ayed AK, Jafar AM, Owayed A (August 2003). "Foreign body aspiration in children: diagnosis and treatment". Pediatr Surg Int. 19 (6): 485–8. doi:10.1007/s00383-003-0965-x. PMID 12736750.
30. ↑ Friedman JN, Rieder MJ, Walton JM (November 2014). "Bronchiolitis: Recommendations for diagnosis, monitoring and management of children one to 24 months of age". Paediatr Child Health. 19 (9): 485–98. doi:10.1093/pch/19.9.485. PMC 4235450. PMID 25414585.
31. ↑ Smith DK, Seales S, Budzik C (January 2017). "Respiratory Syncytial Virus Bronchiolitis in Children". Am Fam Physician. 95 (2): 94–99. PMID 28084708.
32. ↑ Katz SE, Williams DJ (March 2018). "Pediatric Community-Acquired Pneumonia in the United States: Changing Epidemiology, Diagnostic and Therapeutic Challenges, and Areas for Future Research". Infect Dis Clin North Am. 32 (1): 47–63. doi:10.1016/j.idc.2017.11.002. PMC 5801082. PMID 29269189.
33. ↑ Rodrigues C, Groves H (March 2018). "Community-Acquired Pneumonia in Children: the Challenges of Microbiological Diagnosis". J Clin Microbiol. 56 (3). doi:10.1128/JCM.01318-17. PMC 5824044. PMID 29237789. Vancouver style error: initials (help)
34. ↑ Scott JA, Wonodi C, Moïsi JC, Deloria-Knoll M, DeLuca AN, Karron RA, Bhat N, Murdoch DR, Crawley J, Levine OS, O'Brien KL, Feikin DR (April 2012). "The definition of pneumonia, the assessment of severity, and clinical standardization in the Pneumonia Etiology Research for Child Health study". Clin Infect Dis. 54 Suppl 2: S109–16. doi:10.1093/cid/cir1065. PMC 3297550. PMID 22403224.
35. ↑ Thomas TA (August 2017). "Tuberculosis in Children". Pediatr Clin North Am. 64 (4): 893–909. doi:10.1016/j.pcl.2017.03.010. PMC 5555046. PMID 28734517.
36. ↑ Marais BJ, Schaaf HS (July 2014). "Tuberculosis in children". Cold Spring Harb Perspect Med. 4 (9): a017855. doi:10.1101/cshperspect.a017855. PMC 4143109. PMID 25037105.
37. ↑ "Cough or difficulty in breathing - Pocket Book of Hospital Care for Children - NCBI Bookshelf".
38. ↑ Jayaprasad N (2016). "Heart Failure in Children". Heart Views. 17 (3): 92–99. doi:10.4103/1995-705X.192556. PMC 5105230. PMID 27867456.
39. ↑ Juchet A, Brémont F, Dutau G, Olives JP (August 2001). "[Chronic cough and gastroesophageal reflux in children]". Arch Pediatr (in French). 8 Suppl 3: 629–634. doi:10.1016/s0929-693x(01)80018-x. PMID 11683086.CS1 maint: Unrecognized language (link)
40. ↑ Chang AB, Cox NC, Faoagali J, Cleghorn GJ, Beem C, Ee LC, Withers GD, Patrick MK, Lewindon PJ (February 2006). "Cough and reflux esophagitis in children: their co-existence and airway cellularity". BMC Pediatr. 6: 4. doi:10.1186/1471-2431-6-4. PMC 1409774. PMID 16504152.
41. ↑ Chang AB, Glomb WB (January 2006). "Guidelines for evaluating chronic cough in pediatrics: ACCP evidence-based clinical practice guidelines". Chest. 129 (1 Suppl): 260S–283S. doi:10.1378/chest.129.1_suppl.260S. PMID 16428719.
42. ↑ "Prevalence of cough throughout childhood: A cohort study".
43. ↑ Irwin RS, Baumann MH, Bolser DC, Boulet LP, Braman SS, Brightling CE, Brown KK, Canning BJ, Chang AB, Dicpinigaitis PV, Eccles R, Glomb WB, Goldstein LB, Graham LM, Hargreave FE, Kvale PA, Lewis SZ, McCool FD, McCrory DC, Prakash U, Pratter MR, Rosen MJ, Schulman E, Shannon JJ, Hammond CS, Tarlo SM (January 2006). "Diagnosis and management of cough executive summary: ACCP evidence-based clinical practice guidelines". Chest. 129 (1 Suppl): 1S–23S. doi:10.1378/chest.129.1_suppl.1S. PMC 3345522. PMID 16428686. Vancouver style error: initials (help)
44. ↑ Hope-Simpson RE, Miller DL (November 1973). "The definition of acute respiratory illnesses in general practice". Postgrad Med J. 49 (577): 763–70. doi:10.1136/pgmj.49.577.763. PMC 2495832. PMID 4806394.
45. ↑ 45.0 45.1 Hay AD, Wilson AD (May 2002). "The natural history of acute cough in children aged 0 to 4 years in primary care: a systematic review". Br J Gen Pract. 52 (478): 401–9. PMC 1314298. PMID 12014540.
46. ↑ 46.0 46.1 Chang AB, Landau LI, Van Asperen PP, Glasgow NJ, Robertson CF, Marchant JM, Mellis CM (April 2006). "Cough in children: definitions and clinical evaluation". Med J Aust. 184 (8): 398–403. doi:10.5694/j.1326-5377.2006.tb00290.x. PMID 16618239.
47. ↑ 47.0 47.1 "Cough • 2: Chronic cough in children | Thorax".
48. ↑ 48.0 48.1 Gadomski AM, Aref GH, Hassanien F, el Ghandour S, el-Mougi M, Harrison LH, Khallaf N, Black RE (December 1993). "Caretaker recognition of respiratory signs in children: correlation with physical examination findings, x-ray diagnosis and pulse oximetry". Int J Epidemiol. 22 (6): 1166–73. doi:10.1093/ije/22.6.1166. PMID 8144301.
49. ↑ Ciet P, Tiddens HA, Wielopolski PA, Wild JM, Lee EY, Morana G, Lequin MH (December 2015). "Magnetic resonance imaging in children: common problems and possible solutions for lung and airways imaging". Pediatr Radiol. 45 (13): 1901–15. doi:10.1007/s00247-015-3420-y. PMC 4666905. PMID 26342643.
50. ↑ Goldman RD (November 2011). "Treating cough and cold: Guidance for caregivers of children and youth". Paediatr Child Health. 16 (9): 564–9. doi:10.1093/pch/16.9.564. PMC 3223897. PMID 23115499.
51. ↑ "Guidelines for Evaluating Chronic Cough in Pediatrics - CHEST".
52. ↑ Krishnan S, Ianotti V, Welter J, Gallagher MM, Ndjatou T, Dozor AJ (2019). "Bronchodilators, Antibiotics, and Oral Corticosteroids Use in Primary Care for Children With Cough". Glob Pediatr Health. 6: 2333794X19831296. doi:10.1177/2333794X19831296. PMC 6390215. PMID 30828592.