Cough resident survival guide (pediatrics)

| Resident
Survival
Guide

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief:  Maysoon Fatahi, MD[2],Tayyaba Ali, M.D.[3], Huda A. Karman, M.D.

Synonyms and keywords: Cough in childhood, Cough in children, An approach to cough in children

Cough resident survival guide (pediatrics) Microchapters

Overview
Causes
Diagnosis
Treatment
Do's
Don'ts

## Overview

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Cough is a sudden, often repetitive, spasmodic contraction of the thoracic cavity, resulting in a violent release of air from the lungs, and usually accompanied by a distinctive sound. A cough by itself is not a complete diagnosis but rather a symptom of an underlying condition, despite this, it accounts as one of the most common indications for visits to the general practitioners and family physicians with a good proportion of these cases resulting in a pulmonology referral. Coughing is an action the body takes to get rid of substances that are irritating the air passages. The act of coughing can be triggered by a myriad of conditions physiologic and otherwise. A cough is mostly initiated to clear a buildup of phlegm within the trachea. Coughing can also be triggered by a bolus of food entering the trachea and other parts of the respiratory tree rather than the esophagus due to a failure of the epiglottis function.

## Causes

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### Life Threatening Causes

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Life-threatening causes include conditions that may result in death or permanent disability within 24 hours if left untreated:

* Pulmonary embolism [1]
* Pneumonia [2]
* Acute exacerbation of asthma _American_Academy_of_Pediatrics-3|[3]

### Common Causes

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Acute cough (less than 3 weeks)[4] |  Subacute (3 to 8 weeks) or chronic cough (3 to 4 months)[5]

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* Common cold
* Bronchitis or Bronchiolitis
* Asthma
* Pertussis
* Croup
* Influenza
* Foreign body
* Pneumonia
* Second-hand smoke
* Gastroesophageal reflux disease (GERD) [4]

Isolated cough: otherwise healthy child

* Recurrent viral bronchitis
* Postnasal dribbling
* Cough variant asthma
* Psychogenic cough
* Habit cough (tic like)
* Bizarre honking cough
* Gastroesophageal reflux
* Cystic fibrosis
* Retained foreign body
* Primary ciliary dyskinesia
* Immune deficiencies
* Chronic bronchitis
* Airway lesions
* Compression, e.g. tuberculous gland
* Malacia, often with viral infection, e.g. Tracheoesophageal fistula cough [5]

## Diagnosis

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The approach to diagnosis of Cough in children is based on a step-wise testing strategy. Below is an algorithm summarising the identification and laboratory diagnosis of Cough.[6][7]

Cough

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Characterize the symptoms
❑ Chronic wet/productive cough
❑ Chest pain
❑ History suggestive of inhaled foreign body
❑ Dyspnea
❑ Exertional dyspnea
❑ Hemoptysis
❑ Failure to thrive
❑ Choking
❑ Vomiting
❑ Cardiac anomaly
❑ Neurodevelopmental abnormalities
❑ Recurrent sinopulmonary infections
❑ Immunodeficiency
❑ Epidemiologic risk factors for exposure to TB

Examine the patient
❑ Respiratory distress
❑ Digital clubbing
❑ Chest wall deformity
❑ Auscultatory crackles

Order Chest X-ray or spirometry (if child is able to perform)

Wet Cough or Productive Cough with sputum

Dry Cough

Consider the diagnosis of Bacterial bronchitis

Consider the diagnosis of Asthma
❑ History of bilateral wheeze and exertional dyspnea
❑ Absence of other cough symptoms
❑ Absence of findings on lung examination
❑ Reversible obstructive defect or normal finding on spirometry (if performed)

Consider the diagnosis of Retained foreign body
❑ History of choking or sudden onset of symptoms
❑ Monophonic or unilateral wheeze
❑ Chest X-ray finding suggesting foreign body

Consider the other type of cough
❑ Tracheomalacia
❑ Pertussis
❑ Habit cough/ tic cough (typically absent at night or when distracted and may be honking or short/dry)

Antibiotics for 2 to 4 weeks

Trial of Asthma therapies for 2 to 4 weeks

Perform rigid bronchoscopy for foreign body removal

Perform tests to confirm the diagnosis and treat as appropriate

Cough resolves
❑ Likely bacterial bronchitis
❑ Reassess in 3 to 4 months to confirm that child remains well

Productive cough continues after 4 weeks
❑ Consider the diagnosis of:

* Tuberculosis
* Primary ciliary dyskinesia
* Cystic fibrosis
* Bronchiectasis

Asthma Improved
❑ Continue treatment
Asthma not improved
❑ Reassess for other causes of cough

No foreign body
❑ Reassess for other causes of cough

## Treatment

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Shown below is an algorithm summarizing the treatment of underlying conditions that cause cough.

### Acute cough

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Treat the underlying causes

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Cough due to Bronchiolitis[8]
❑ Supportive care such as hydration, saline nasal drops, nasal bulb suction
❑ Prevention includes Palivizumab for infants with the following conditions:

* Preterm birth less than 29 weeks gestation
* Chronic lung disease of prematurity
* Hemodynamically significant congenital heart disease

Cough due to Common Cold[9]
❑ Supportivr care such as hydration, saline nasal drops
❑ Combination of over the counter medications such as antihistamines, decongestants, antitussives, expectorants, mucolytics, antipyretics/analgesics
❑ For fever, acetaminophen (for children older than three months) or ibuprofen (for children older than six months)

Cough due to Asthma[10][11]

❑ Humidified oxygen by nasal cannula or facemask

❑ Inhaled short-acting beta-2 agonists (SABAs) such as (albuterol/salbutamol)

❑ Systemic glucocorticoids (Oral prednisone or dexamethasone)

❑ ICU admission for severe exacerbation

* Systemic beta-agonists, methylxanthines, and magnesium sulfate
* noninvasive positive pressure ventilation and high-flow nasal cannula

❑ Antibiotics for bacterial pneumonia or sinusitis

Cough due to Pertussis[12][13]

❑ Macrolides erythromycin, clarithromycin, and azithromycin are preferred for the treatment of pertussis in persons 1 month of age and older

❑ Azithromycin remains the drug of choice for treatment or prophylaxis of pertussis in infants younger than 1 month of age,

❑ Monitor the infant for the development of infantile hypertrophic pyloric stenosis (IHPS) with the use of oral erythromycin and azithromycin

❑ An alternative to macrolides is trimethoprim-sulfamethoxazole in infants 2 months of age and older

Cough due to Croup[14][15][16]

❑ Comfort measures (keep the child calm as crying worsen airway obstruction

❑ A single dose of dexamethasone if symptoms persist for>3-5 days or worsen

❑ An inhaled epinephrine using a nebulizer for more severe symptoms

Cough due to Pneumonia[17][18][19]

Inpatient treatment

❑ Supportive care

* Antipyretics and/or analgesics (acetaminophen, ibuprofen)

❑ Supplemental oxygen to maintain oxygen saturation ≥95 percent

❑ IV fluid therapy

❑ IV empiric antibiotic treatment

* 1-6 months old (Ceftriaxone or Cefotaxime)
* ≥6 months (Ampicillin or penicillin G is preferred)
* For C. trachomatis, M. pneumoniae or C. pneumoniae (Azithromycin)

❑ For Severe pneumonia

* Ceftriaxone or Cefotaxime plus Macrolide (Azithromycin)

❑ ICU admission

* Vancomycin plus Ceftriaxone or Cefotaxime plus Azithromycin plus Antiviral if hospitalized during influenza season)

❑ Complicated pneumonia

* Ceftriaxone or Cefotaxime plus Clindamycin if S. aureus or anaerobic is suspected

Cough due to Influenza_CDC-20|[20]

❑ Oral oseltamivir for:

* Hospitalized patients
* Patients with severe, complicated, or progressive illness
* Patients with risk factors for complications

### Chronic cough

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Treat the underlying causes

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Cough due to Cystic fibrosis[21][22][23][24]

❑ CFTR modulator such as tezacaftor-ivacaftor or lumacaftor-ivacaftor

* CFTR genotyping should be done first to determine the patient eligibility
* Patients ≥12 years old with responsive CFTR mutations
* Younger patients with sufficient evidence for FDA approval

❑ Metered-dose Albuterol Inhaler

❑ Hypertonic saline

❑ DNase such as dornase alfa

❑ Chest physiotherapy

❑ Exercise

❑ Aerosolized antibiotics or long-acting antiasthmatics

❑ Azithromycin

* Chronic treatment with for patients six years and older

Cough due to Chronic bronchitis

protracted bacterial bronchitis

❑ Augmentin (amoxicillin and clavulanate potassium) or Omnicef (cefdinir)

Cough due to Primary ciliary dyskinesia[25][26][27] 9387968

❑ Treatment should be individualized based on the clinical course of each patient

❑ Supplemental oxygen for a few hours to days after birth for mild respiratory distress (tachypnea, mild hypoxemia)

Bronchiectasis

❑ Daily chest physiotherapy

❑ Oral antibiotics for acute exacerbation and it should be tailored based on the sputum culture results

❑ Preventive antibiotic therapy with Azithromycin may reduce the rate of exacerbations

* Do Sputum cultures prior to Azithromycin use to exclude nontuberculous mycobacteria infection
* Assess for risk of QT interval prolongation prior to Azithromycin use

Cough due to Postnasal drib (Allergic Rhinitis)[28]

❑ Antihistamines

❑ Nasal steroid sprays reduce swelling and inflammation of the nasal passages promoting proper drainage

❑ Allergy shots (immunotherapy) if no improvement

Cough due to Cough variant asthma[29]

❑ Inhaler with albuterol, ipratropium, and/or inhaled steroids

Cough due to Recurrent viral bronchitis

❑ Antibiotics are not recommended except with chronic wet cough for ≥ 2-4 weeks, which could be mostly bacterial ❑ Albuterol or terbutaline inhalers ❑ corticosteroids if no improvement ❑ Stepped-up courses of inhaled corticosteroids might be effective ❑

Cough due to Asthma[30][31]

Mild, persistent asthma ❑ low-dose, daily inhaled glucocorticoids ❑ Daily leukotriene receptor antagonist (Montelukast )

* As an alternative to inhaled glucocorticoids
* Limited use due to neuropsychiatric sede effects

## Do's

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* "For children aged less than 14-years with chronic cough (> 4 weeks duration) without an underlying lung disease but who have symptoms and signs or tests consistent with gastroesophageal pathological reflux, they should be treated for GERD in accordance to evidence-based GERD specific guidelines (Grade 1B)." [32]_Gastro-oesophageal_reflux_disease_in_children_and_young_people:_diagnosis_and_management_|_Guidance_|_NICE-33|[33]
* "Children with chronic cough and typical symptoms of GERD should undergo medical treatment—dietary, lifestyle modifications and acid suppression therapy. A three-stage therapeutic trial should be completed before diagnosing reflux-related cough:

(1) clear-cut response to a 4 to 8-week treatment with PPI

(2) relapse on stopping medication

(3) new response to recommencing medication, with weaning down therapy as appropriate to the child’s symptoms." [34]

## Don'ts

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* According to Chang et al., "for children aged less than 14-years with chronic cough (> 4 weeks duration) without an underlying lung disease, treatment for gastroesophageal reflux disease (GERD) should not be used when there are no clinical features of gastroesophageal reflux such as recurrent regurgitation, dystonic neck posturing in infants, or heartburn/epigastric pain in older children (Grade1B)." [35]
* For children aged less than 14-years with chronic cough (> 4 weeks duration) without an underlying lung disease but who have symptoms and signs or tests consistent with gastroesophageal pathological reflux, acid suppressive therapy should not be used solely for their chronic cough (Grade 1C). [35]
* According to CHEST guidelines 2017, "For children aged less than 14-years with chronic cough, basing the management on the etiology of the cough is recommended. An empirical approach aimed at treating upper airway cough syndrome due to a rhinosinus condition, GERD and/or asthma should not be used unless other features consistent with these conditions are present." [36]
* “In otherwise well children with nonspecific cough, empirical gastroesophageal reflux therapy is unlikely to be beneficial and is generally not recommended.” [34]

## References

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1. ↑ Patocka C, Nemeth J (2012). "Pulmonary embolism in pediatrics". J Emerg Med. 42 (1): 105–16. doi:10.1016/j.jemermed.2011.03.006. PMID 21530139.
2. ↑ Tan TQ, Mason EO, Wald ER, Barson WJ, Schutze GE, Bradley JS; et al. (2002). "Clinical characteristics of children with complicated pneumonia caused by Streptococcus pneumoniae". Pediatrics. 110 (1 Pt 1): 1–6. doi:10.1542/peds.110.1.1. PMID 12093940.CS1 maint: Multiple names: authors list (link)
3. _American_Academy_of_Pediatrics_3-0|↑ "Acute Asthma: Observations Regarding the Management of a Pediatric Emergency Room | American Academy of Pediatrics".
4. ↑ 4.0 4.1 "www.ncbi.nlm.nih.gov" (PDF).
5. ↑ 5.0 5.1 de Jongste JC, Shields MD (2003). "Cough . 2: Chronic cough in children". Thorax. 58 (11): 998–1003. doi:10.1136/thorax.58.11.998. PMC 1746521. PMID 14586058.
6. ↑ Rochwerg B, Brochard L, Elliott MW, Hess D, Hill NS, Nava S; et al. (2017). "Official ERS/ATS clinical practice guidelines: noninvasive ventilation for acute respiratory failure". Eur Respir J. 50 (2). doi:10.1183/13993003.02426-2016. PMID 28860265.CS1 maint: Multiple names: authors list (link)
7. ↑ Weinberger M, Hoegger M (2016). "The cough without a cause: Habit cough syndrome". J Allergy Clin Immunol. 137 (3): 930–1. doi:10.1016/j.jaci.2015.09.002. PMID 26483178.
8. ↑ King VJ, Viswanathan M, Bordley WC, Jackman AM, Sutton SF, Lohr KN; et al. (2004). "Pharmacologic treatment of bronchiolitis in infants and children: a systematic review". Arch Pediatr Adolesc Med. 158 (2): 127–37. doi:10.1001/archpedi.158.2.127. PMID 14757604.CS1 maint: Multiple names: authors list (link)
9. ↑ "Treatment of the Common Cold - American Family Physician".
10. ↑ Ben-Zvi Z, Lam C, Hoffman J, Teets-Grimm KC, Kattan M (1982). "An evaluation of the initial treatment of acute asthma". Pediatrics. 70 (3): 348–53. PMID 7110806.CS1 maint: Multiple names: authors list (link)
11. ↑ Rodrigo GJ, Rodriquez Verde M, Peregalli V, Rodrigo C (2003). "Effects of short-term 28% and 100% oxygen on PaCO2 and peak expiratory flow rate in acute asthma: a randomized trial". Chest. 124 (4): 1312–7. doi:10.1378/chest.124.4.1312. PMID 14555560.CS1 maint: Multiple names: authors list (link)
12. ↑ Tozzi AE, Celentano LP, Ciofi degli Atti ML, Salmaso S (2005). "Diagnosis and management of pertussis". CMAJ. 172 (4): 509–15. doi:10.1503/cmaj.1040766. PMC 548414. PMID 15710944.CS1 maint: Multiple names: authors list (link)
13. ↑ Tablan OC, Anderson LJ, Besser R, Bridges C, Hajjeh R, CDC; et al. (2004). "Guidelines for preventing health-care--associated pneumonia, 2003: recommendations of CDC and the Healthcare Infection Control Practices Advisory Committee". MMWR Recomm Rep. 53 (RR-3): 1–36. PMID 15048056.CS1 maint: Multiple names: authors list (link)
14. ↑ Gates A, Gates M, Vandermeer B, Johnson C, Hartling L, Johnson DW; et al. (2018). "Glucocorticoids for croup in children". Cochrane Database Syst Rev. 8: CD001955. doi:10.1002/14651858.CD001955.pub4. PMC 6513469 Check `|pmc=` value (help). PMID 30133690.CS1 maint: Multiple names: authors list (link)
15. ↑ Westley CR, Cotton EK, Brooks JG (1978). "Nebulized racemic epinephrine by IPPB for the treatment of croup: a double-blind study". Am J Dis Child. 132 (5): 484–7. doi:10.1001/archpedi.1978.02120300044008. PMID 347921.CS1 maint: Multiple names: authors list (link)
16. ↑ Klassen TP, Watters LK, Feldman ME, Sutcliffe T, Rowe PC (1996). "The efficacy of nebulized budesonide in dexamethasone-treated outpatients with croup". Pediatrics. 97 (4): 463–6. PMID 8632929.CS1 maint: Multiple names: authors list (link)
17. ↑ Bradley JS, Byington CL, Shah SS, Alverson B, Carter ER, Harrison C; et al. (2011). "The management of community-acquired pneumonia in infants and children older than 3 months of age: clinical practice guidelines by the Pediatric Infectious Diseases Society and the Infectious Diseases Society of America". Clin Infect Dis. 53 (7): e25–76. doi:10.1093/cid/cir531. PMC 7107838 Check `|pmc=` value (help). PMID 21880587.CS1 maint: Multiple names: authors list (link)
18. ↑ Harris M, Clark J, Coote N, Fletcher P, Harnden A, McKean M; et al. (2011). "British Thoracic Society guidelines for the management of community acquired pneumonia in children: update 2011". Thorax. 66 Suppl 2: ii1–23. doi:10.1136/thoraxjnl-2011-200598. PMID 21903691.CS1 maint: Multiple names: authors list (link)
19. ↑ Chang CC, Cheng AC, Chang AB (2014). "Over-the-counter (OTC) medications to reduce cough as an adjunct to antibiotics for acute pneumonia in children and adults". Cochrane Database Syst Rev (3): CD006088. doi:10.1002/14651858.CD006088.pub4. PMID 24615334.CS1 maint: Multiple names: authors list (link)
20. _CDC_20-0|↑ "Influenza Antiviral Medications: Summary for Clinicians | CDC".
21. ↑ Heijerman HGM, McKone EF, Downey DG, Van Braeckel E, Rowe SM, Tullis E; et al. (2019). "Efficacy and safety of the elexacaftor plus tezacaftor plus ivacaftor combination regimen in people with cystic fibrosis homozygous for the F508del mutation: a double-blind, randomised, phase 3 trial". Lancet. 394 (10212): 1940–1948. doi:10.1016/S0140-6736(19)32597-8. PMID 31679946.CS1 maint: Multiple names: authors list (link)
22. ↑ Walker S, Flume P, McNamara J, Solomon M, Chilvers M, Chmiel J; et al. (2019). "A phase 3 study of tezacaftor in combination with ivacaftor in children aged 6 through 11 years with cystic fibrosis". J Cyst Fibros. 18 (5): 708–713. doi:10.1016/j.jcf.2019.06.009. PMID 31253540.CS1 maint: Multiple names: authors list (link)
23. ↑ Flume PA, O'Sullivan BP, Robinson KA, Goss CH, Mogayzel PJ, Willey-Courand DB; et al. (2007). "Cystic fibrosis pulmonary guidelines: chronic medications for maintenance of lung health". Am J Respir Crit Care Med. 176 (10): 957–69. doi:10.1164/rccm.200705-664OC. PMID 17761616.CS1 maint: Multiple names: authors list (link)
24. ↑ Mogayzel PJ, Naureckas ET, Robinson KA, Mueller G, Hadjiliadis D, Hoag JB; et al. (2013). "Cystic fibrosis pulmonary guidelines. Chronic medications for maintenance of lung health". Am J Respir Crit Care Med. 187 (7): 680–9. doi:10.1164/rccm.201207-1160oe. PMID 23540878.CS1 maint: Multiple names: authors list (link)
25. ↑ Knowles MR, Daniels LA, Davis SD, Zariwala MA, Leigh MW (2013). "Primary ciliary dyskinesia. Recent advances in diagnostics, genetics, and characterization of clinical disease". Am J Respir Crit Care Med. 188 (8): 913–22. doi:10.1164/rccm.201301-0059CI. PMC 3826280. PMID 23796196.CS1 maint: Multiple names: authors list (link)
26. ↑ Hosie PH, Fitzgerald DA, Jaffe A, Birman CS, Rutland J, Morgan LC (2015). "Presentation of primary ciliary dyskinesia in children: 30 years' experience". J Paediatr Child Health. 51 (7): 722–6. doi:10.1111/jpc.12791. PMID 25510893.CS1 maint: Multiple names: authors list (link)
27. ↑ Barbato A, Frischer T, Kuehni CE, Snijders D, Azevedo I, Baktai G; et al. (2009). "Primary ciliary dyskinesia: a consensus statement on diagnostic and treatment approaches in children". Eur Respir J. 34 (6): 1264–76. doi:10.1183/09031936.00176608. PMID 19948909.CS1 maint: Multiple names: authors list (link)
28. ↑ Pratter MR (2006). "Chronic upper airway cough syndrome secondary to rhinosinus diseases (previously referred to as postnasal drip syndrome): ACCP evidence-based clinical practice guidelines". Chest. 129 (1 Suppl): 63S–71S. doi:10.1378/chest.129.1_suppl.63S. PMID 16428694.
29. ↑ Pender ES, Pollack CV (1990). "Cough-variant asthma in children and adults: case reports and review". J Emerg Med. 8 (6): 727–31. doi:10.1016/0736-4679(90)90287-6. PMID 2096171.
30. ↑ Childhood Asthma Management Program Research Group. Szefler S, Weiss S, Tonascia J, Adkinson NF, Bender B; et al. (2000). "Long-term effects of budesonide or nedocromil in children with asthma". N Engl J Med. 343 (15): 1054–63. doi:10.1056/NEJM200010123431501. PMID 11027739.CS1 maint: Multiple names: authors list (link)
31. ↑ Jartti T (2008). "Inhaled corticosteroids or montelukast as the preferred primary long-term treatment for pediatric asthma?". Eur J Pediatr. 167 (7): 731–6. doi:10.1007/s00431-007-0644-3. PMID 18214538.
32. ↑ Rosen R, Vandenplas Y, Singendonk M, Cabana M, DiLorenzo C, Gottrand F; et al. (2018). "Pediatric Gastroesophageal Reflux Clinical Practice Guidelines: Joint Recommendations of the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition and the European Society for Pediatric Gastroenterology, Hepatology, and Nutrition". J Pediatr Gastroenterol Nutr. 66 (3): 516–554. doi:10.1097/MPG.0000000000001889. PMC 5958910. PMID 29470322.CS1 maint: Multiple names: authors list (link)
33. _Gastro-oesophageal_reflux_disease_in_children_and_young_people:_diagnosis_and_management_|_Guidance_|_NICE_33-0|↑ "Overview | Gastro-oesophageal reflux disease in children and young people: diagnosis and management | Guidance | NICE".
34. ↑ 34.0 34.1 de Benedictis FM, Bush A (2018). "Respiratory manifestations of gastro-oesophageal reflux in children". Arch Dis Child. 103 (3): 292–296. doi:10.1136/archdischild-2017-312890. PMID 28882881.
35. ↑ 35.0 35.1 "journal.chestnet.org".
36. ↑ Chang AB, Oppenheimer JJ, Weinberger MM, Rubin BK, Grant CC, Weir K; et al. (2017). "Management of Children With Chronic Wet Cough and Protracted Bacterial Bronchitis: CHEST Guideline and Expert Panel Report". Chest. 151 (4): 884–890. doi:10.1016/j.chest.2017.01.025. PMID 28143696.CS1 maint: Multiple names: authors list (link)