Paediatric medicine - Management of acute cough in children

Dr Atul Gupta and Professor Andrew Bush offer their insights on this common presenting symptom.

Chest X-ray of a child with foreigh body in right main bronchus (Photograph: Author Image)

Cough is an important protective reflex, enabling airway secretions to be cleared. Cough is one of the most common presenting symptoms in children. In the community, most children with a cough will not have any serious underlying aetiology.

Most coughs are acute and related to viral infections; however, there are a number of differential diagnoses to consider when cough frequency or severity is abnormal.

Differential diagnoses include pneumonia, hay fever or an inhaled foreign body. For patient and parents, a cough that persists can cause considerable distress and lead to impaired quality of life.

Presentation
Acute cough is defined as a recent onset of cough lasting less than three weeks. It may be the first presentation of a chronic disorder.

For the majority of children the cough will resolve by 14 days, however, for a significant minority the cough will take three to four weeks to resolve. Note that more than 10 per cent of preschool children will have more than 10 colds per year.1

The absence of fever, tachy-pnoea (respiratory rate varies with age and tachypnoea is defined as respiratory rate >60/min for <2 months, >50/min for 2-12 months, and >40/min for >1 year of age) and chest signs are useful for ruling out future complications in children with cough in primary care.

In the presence of these signs and symptoms a thorough clinical review is required to identify an underlying respiratory and/or systemic illness.

A choking episode may not have been witnessed but cough of sudden onset or presence of asymmetrical wheeze or hyperinflation may be due to the child inhaling a foreign body.

Reassure the parents
Cough can cause significant distress to the whole family, so it is important to explore the reasons for parental anxiety and offer reassurance.

Providing parents with information on the expected time to resolution of acute respiratory infections may reduce anxiety and the need for medication use and additional consultations.

It is equally as important to detect environmental exacerbating factors (such as passive smoke exposure) and to attempt to eliminate them as far as possible.

Investigations
Most children will not need any investigations, assuming the cough abates completely.

If there is a history suggestive of a foreign body, then urgent referral for bronchoscopy is essential.

A chest radiograph is only indicated in presence of lower respiratory tract signs, haemoptysis or features of an undiagnosed chronic respiratory disease, for example failure to thrive, finger clubbing, over-inflated chest, chest deformity or features of atopy.

An expiratory film may help in acute bronchial obstruction, but a normal chest X-ray does not exclude a foreign body.

Treatments
OTC medications for acute cough with head colds are as effective as placebo but have the potential to cause side-effects.

Bronchodilators are of no benefit for acute cough in non-asthmatic children.

Antibiotics are not recommended for treating 'simple' acute coughs. In children with suspected pertussis, early macrolide antibiotics are indicated as they can alter the clinical course and reduce infectivity.

Antihistamines and intra-nasal steroids are only beneficial for allergic cough in the pollen season.

Parents should be warned that information obtained from the internet may be unreliable. According to a study, out of the 19 website pages, 10 contained more incorrect than correct information and only one appeared to be mostly correct.2

Prolonged acute cough
Sub-acute cough has a duration of three to eight weeks. A period of observation may be needed to determine if further investigations will be required.

If the cough is abating and the child is otherwise well, no further tests are required; however, it is important to follow up the child in six to eight weeks to ensure the cough has resolved.

If the cough is progressive after three weeks (increasingly severe in frequency or/and severity) further investigations are required.

The need for referral to secondary care is judged on an individual, clinical basis. A normal chest X-ray does not exclude disease.

Underlying illness
In the management of any child with cough, irrespective of the aetiology, attention to exacerbation factors is encouraged.

Cough in children is very common and, in the majority, is reflective of expected childhood respiratory infections in an otherwise normal child.

However, cough may also be the first sign of a significant serious disorder and all children with cough should have a thorough clinical review to identify any worrying feature suggestive of an underlying respiratory or systemic illness.

  • Dr Gupta is specialist registrar and Professor Bush is honorary consultant paediatric chest physician, Royal Brompton Hospital, London

Serious signs and symptoms

  • Symptoms/signs suggestive of serious underlying lung disease in children with cough
  • Neonatal onset of cough.
  • Chronic moist/productive cough.
  • Cough started and persists after choking episode.
  • Very sudden onset of cough.
  • Cough occurs during or after feeding.
  • Haemoptysis.
  • Digital clubbing.
  • Abnormal auscultatory findings, particularly if asymmetric.
  • Chest wall deformity.
  • Failure to thrive.
  • Cardiac abnormalities.
  • Features suggestive of immune deficiency, such as significant extrapulmonary infection.
  • Recurrent radiologically confirmed pneumonia.

References

1. Leder K, Sinclair M I, Mitakakis TZ et al. A community based study of respiratory episodes in Melbourne, Australia. Aust NZ J Public Health 2003; 27: 399-404.

2. Pandolfini C, Impicciatore P, Bonati M. Parents on the web: risks for quality management of cough in children. Pediatrics 2000; 105: e1.

Further reading

  • Shields M D, Bush A, Everard ML, et al. BTS guidelines: Recommendations for the assessment and management of cough in children. Thorax 2008; 63 Suppl 3: iii1-iii15.
  • Gupta A, McKean M, Chang A B. Management of chronic non-specific cough in childhood: an evidence-based review. Arch Dis Child Educ Pract Ed 2007; 92(2): 33-9.

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