Cough is one of the most common presenting symptoms in children, and is more common in preschool children than school 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 of acute cough include pneumonia, hay fever, or an inhaled foreign body. Cough is an important protective reflex, enabling airway secretions to be cleared. For patients and parents, a cough that persists can cause considerable distress and lead to an impaired quality of life.
Because acute cough has a different range of causes in children younger than 18 years of age than it does in adults, children should be assessed and treated differently. 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 3-4 weeks to resolve. Note that more than 10 per cent of preschool children will have more than 10 colds per year.
The absence of fever, tachypnoea (respiratory rate varies with age and tachypnoea is defined as respiratory rate >60/min for less than 2 months, less than 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.
Most children will not need any investigations, assuming the cough abates completely. If there is a history suggestive of a foreign body, urgent referral for bronchoscopy is essential.
A chest radiograph is only indicated in the 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 the presence of a foreign body.
In general, there are fewer randomised controlled trials in children than in adults, so the evidence is poor, and an important aspect of treating children is to pay attention to parental concerns and expectations. Evidence-based guidelines have shown that there are no effective medications to either cure or relieve the symptoms of acute cough in children.
Over-the-counter 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 as they have no effect on viral infections. In children with suspected pertussis, early macrolide antibiotics are indicated as they can alter the clinical course and reduce infectivity.
There is good evidence that oral corticosteroids are an effective treatment for moderate to severe croup. 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 of 19 website pages, 10 contained more incorrect than correct information, and only one appeared to be mostly correct.1
Prolonged acute cough
Sub-acute cough has a duration of 3-8 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 6-8 weeks to ensure the cough has resolved. If the cough is progressive after 3 weeks (increasingly severe in frequency and/or severity) further investigations are required.
The need for referral to secondary or tertiary care is judged on an individual, clinical basis. A normal chest X-ray does not exclude disease.
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.
|SERIOUS SIGNS AND SYMPTOMS|
|Symptoms/signs suggestive of serious underlying lung disease in children with cough include:
Immediate clinical evaluation is required in cases of acute cough when:
- The child is working hard to breathe, perhaps with chest retractions
- There are coughing spasms with cyanosis
- There are apnoeic episodes
- There is haemoptysis
- There is suspected airway foreign body aspiration.
- Dr Atul Gupta, Consultant in paediatric respiratory medicine, King’s College Hospital, London, UK
- Pandolfini C, Impicciatore P, Bonati M. Parents on the web: risks for quality management of cough in children. Pediatrics 2000; 105: e1.
Shields MD, 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 AB. Management of chronic non-specific cough in childhood: an evidence-based review. Arch Dis Child Educ Pract Ed 2007; 92(2): 33-9.