COUGH IN CHILDREN

Grażyna Górnicka

COUGH IN CHILDREN

• Coughs are one of the most common

symptoms of childhood illness. Although a

cough can sound awful, it's not usually a

sign of a serious condition.

• In fact, coughing is a healthy and

important reflex that helps protect the

airways in the throat and chest.

• Coughs tend to linger on in young children,

often disturbing sleep and everyday

functioning. They can be upsetting for

children and parents alike.

Causes of a cough

• There are many causes of a cough in

children, including:

• infections

(both viral and bacterial),

• irritations

(cold air, smoke, inhaled

foreign body),

• allergies,
• asthma and
• psychological causes (habit cough).

Understanding what different types of cough could

mean will help to diagnose of illness

"Barky" Cough

• Barky coughs are usually caused by a swelling in

the upper part of the airway. Most of the time, a

barky cough comes from

croup

, a swelling of the

larynx (voice box) and trachea (windpipe).

• Croup usually is the result of a virus, but can also

come from allergies or a change in temperature at

night.

• Kids younger than 3 years old are at the most risk

for croup because their airways are so narrow.

• A cough from croup can start suddenly and in the

middle of the night. Often a kid with croup will also

have stridor, which is a noisy, harsh breathing

(often described as a coarse, musical sound) that

occurs when a child inhales.

Whooping Cough

• is another name for pertussis, an infection of the

airways caused by the bacteria Bordetella pertussis.

Kids with pertussis will have spells of back-to-back

coughs without breathing in between. At the end of
the coughing, they'll take a deep breath in that makes
a "whooping" sound.

Whooping cough begins like the common cold about a

week after exposure. But 10 to 12 days later the
coughing fits begin, they can last for more than a
minute, and the patient may turn red or purple from
lack of air (the "whoop" is a desperate gasp to
breath!)

Whooping Cough

Other symptoms of pertussis are a runny

nose, sneezing, mild cough, and a low-
grade fever.

• Although pertussis can happen at any age,

it's most severe

in infants under 1 year old

who did not get the pertussis vaccine.

• Pertussis is very contagious, so child

should get the pertussis shot at 2, 4, 6, 15
months, and 4-6 years of age.

Cough With Wheezing

• If a child makes a wheezing

(whistling) sound when

breathing out

,

this could mean that the lower airways
in the lungs are swollen.

• This can happen with asthma or with a

viral infection (bronchiolitis).

• Also, wheezing can happen if the lower

airway is blocked by a foreign object.

Nighttime Cough

• Lots of coughs get worse at night.
• When a child has a cold, the mucus from

the nose and sinuses can drain down

the throat and trigger a cough during

sleep.

• This is only a problem if the cough won't

let a child sleep.

• Asthma also can trigger nighttime

coughs because the airways tend to be

more sensitive and irritable at night.

Daytime Cough

• Cold air or activity can make coughs

worse during the daytime.

• We must try to make sure that

nothing in patietnt’s house — like air
freshener, pets, or smoke

(especially

tobacco smoke)

— is making child cough.

Cough With a Fever

• A child who has a cough, mild fever,

and runny nose probably has a

common cold

.

• But coughs with a fever of 102° F

(39° C) or higher can sometimes be
due to pneumonia, especially if a
child is weak and breathing fast.

Cough With Vomiting

• Kids often cough so much that it

triggers their gag reflex, making them
vomit.

• Also, a child who has a cough with a

cold or an asthma flare-up might throw
up if lots of mucus drains into the
stomach and causes nausea.

• Usually, this is not cause for alarm

unless the vomiting doesn't stop.

Persistent Cough

• Coughs caused by colds due to viruses can last

weeks, especially if a child has one cold right
after another.

• Asthma, allergies, or a chronic infection in the

sinuses or airways also might cause persistent
coughs.

• If the cough lasts for 3 weeks need to be

diagnosed

Chronic Cough in Children

• Cough in children may arise from

causes anywhere along the airway,
from the nose to the alveoli.

• Cough is a nonspecific reaction to

irritation anywhere from the pharynx to
the lungs. Childhood coughing is a
common problem that can cause
anxiety in parents.

• There are important differences from

adult cough in terms of likely causes
and management guidelines.

• Chronic cough in children is generally defined as

a cough lasting longer than eight weeks.

• This timeframe is used because most simple

infective causes of cough

will resolve in 3-4

weeks

, and the eight-week definition identifies

those who may need further investigations

• The timeframe between acute and chronic cough

(3-8 weeks) is sometimes called „subacute

cough” or 'prolonged acute cough' (e.g. a slowly

resolving post-viral cough).

• If a cough is starting to resolve after three weeks,

further time may be allowed before investigating

further.

• However, if the cough is

not improving

by the

third week or

is increasing in severity

, earlier

investigations may be indicated.

Common causes in primary

care

• Infections

(or recurrent infections) -

including respiratory syncytial virus (RSV),
adenovirus, Mycoplasma pneumoniae,
chlamydial pneumonia, whooping cough
(pertussis) and tuberculosis.

• Asthma.
• Postnasal drip syndrome.
• Environmental agents - tobacco smoke,
• Gastro-oesophageal reflux.

Asthma

• A persistent cough that's often whistling or wheezy, lasts

longer than 10 days, and worsens at night or after a child
exercises or is exposed to pollen, cold air, animal dander,
dust mites, or smoke.

• Other Symptoms: child is wheezing or has labored,

rapid breathing.

• Likely Culprit: Asthma, a chronic condition in which

small airways in the lungs swell, narrow, become clogged
with mucous, and spasm, making breathing difficult.
Common asthma triggers include environmental irritants,
viral infections, and exercise.

• In mild asthma cases, a chronic cough may be the only

symptom,

GERD gastroesophageal reflux

disease

• A wheezy, crackly, persistent cough after a child

eats. Coughing episodes typically worsen when

she's lying down.

• Other Symptoms: child may feel a burning

sensation or may vomit or belch when swallowing.

A baby might be fussy or have been labeled as

colicky. Toddlers may develop wheezing and picky

eating habits.

• GERD , caused by a weak or immature band of

muscle between the esophagus and stomach that

allows acid to flow back up. Sometimes the

irritating juices can enter the lungs, causing a

chronic cough.

GERD gastroesophageal reflux

disease

• What to Do: doctor usually recommend keeping a

baby upright for at least 30 minutes after feedings and

for babies

and older children, elevating the head of their
mattress while they sleep.
• With older children, he may also suggest avoiding

foods and beverages that cause symptoms, such as

caffeinated sodas, chocolate, peppermint, spicy foods

like pizza, acidic foods like orange and tomatoes, and

fried and fatty foods, and not eating within two hours of

bedtime.

• Prescription medicine can also control GERD symptoms.

Less common causes

• Inhaled foreign body

• Cystic fibrosis

• Immune deficiency.

• Congenital lesions,

e.g. tracheo-oesophageal

fistula,

tracheomalacia.

• Ciliary dyskinesia.

• Neurological, e.g. tics, psychogenic

cough. Psychogenic cough may be

bizarre, honking and decrease with

sleep or attention to other activities.

• cystic fibrosis: children with CF can

have a chronic cough, frequent
infections, poor growth and greasy,
foul smelling stools.

Triggers of cough

• Exercise/excitement/cold air/nocturnal

cough/change in environment, e.g. pets -
consider asthma.

• Swallowing/meals - recurrent aspiration.
• Lying down - postnasal drip, gastro-

oesophageal reflux.

• Attention -

psychogenic.

• Angiotensin-converting enzyme (ACE)

medication - ACE inhibitor-induced cough.

Red flags

The following features indicate a

possible serious cause of cough.

History:

• Family history of lung disease.

• Neonatal onset.

• Sudden onset.

• Haemoptysis (true haemoptysis - not, for example,
nosebleeds or cheek biting).

• Cough with feeding, dysphagia, severe vomiting.

• Chronic moist cough with sputum production.

• Night sweats/weight loss.

• Continuous unremitting or worsening cough.

Signs:

• Signs of chronic lung disease, e.g. clubbing.

• Failure to thrive.

• Abnormal voice or crying, inspiratory stridor.

• Focal chest abnormality.

Which children need

investigating

in primary care?

• Generaly - primary care guidelines suggest

the following strategy:

• 'Red flags' present

- require specific

investigations depending on the clinical

picture.

• No 'red flags'

:

– If fever - exclude pneumonia.

– For immigrants - exclude tuberculosis.

– If there are pointers to a specific cause -

investigate appropriately (e.g. spirometry,

serology, oesophageal pH monitoring).

– If there are no specific pointers - consider CXR.

Which investigations?

• BTS guidelines suggest the following strategy when
investigating chronic cough:

Initial investigations:

• CXR.
• Spirometry (or peak flow monitoring in older children) ±

tests of bronchodilator responsiveness or bronchial
hyper-reactivity.

• Further investigations:
• Obtain a sputum sample if possible - for microbiology and

cytology.

• Allergy testing (skin prick or radioallergosorbent test

specific testing) may help if atopy/asthma are likely
diagnoses.

• Other tests will depend on the clinical picture
and differential diagnosis.

Trial of treatment:

• BTS guidelines suggest that in young

children, as it may be difficult to

rule

out asthma

as a cause of coughing ,

a

trial of anti-asthma therapy

may be

used (e.g. inhaled corticosteroids).

• Ensure effective delivery, adequate

doses and clear recording of outcomes.

Trial of treatment:

• Set a time (e.g. 8-12 weeks) after which

the trial of anti-asthma medication

should be stopped.

• If the child has responded to anti-asthma

therapy and the treatment has

subsequently been stopped, an early

relapse that again responds to treatment

is suggestive of cough-variant asthma.

• If there is no response, asthma is

unlikely.

Management

• This depends on any specific cause found.
• In a well child with no 'red flags', aim to

avoid invasive investigations and to
explore the expectations and anxieties of
parents.

• Remove environmental contributions if

possible, e.g. tobacco smoke.

• Antitussive drugs, other than simple cough

linctus, are not generally recommended.

•

EMIS 2011Author: Dr Naomi Hartree

Thank you

for your

attention