chronic cough in children by Micheal Mohab Nady Mikael

1. Chronic Cough in Children
By
Micheal Mohab Nady Mikael
Pediatric Resident

2. Children are “SPECIFIC patients”, and
not “small ADULTS

3. The anatomical localisation of signs and symptoms of
airway irritation and obstruction.

4. What is a cough?
The ERS Task Force recommended two possible
definitions of cough :
(1)‘A three-phase expulsive motor act
 inspiratory effort (inspiratory phase)
 followed by a forced expiratory effort
against a closed glottis (compressive phase)
 and then by opening of the glottis and rapid
expiratory airflow (expulsive phase)’.
Morice AH, et al. ERS guidelines on the assessment of cough. Eur Respir J 2007;29:1256–76

5. What is a cough?
(2) ‘A forced expiratory maneuver, usually
against a closed glottis and associated with a
characteristic sound’.
Morice AH, et al. ERS guidelines on the assessment of cough. Eur Respir J 2007;29:1256–76

6. This definition appears in most textbooks,
which sometimes add a fourth ‘recovery
phase’ (the deep inspiration that usually
follows a cough).
Morice AH, et al. ERS guidelines on the assessment of cough. Eur Respir J 2007;29:1256–76

7. Cough receptors reside in
the
 Larynx and airway bifurcations
 pharynx
 paranasal sinuses
 stomach
 external auditory canal

8. The anatomy of the afferent limb of the cough reflex. Solid dots represent
receptors, circled dot represents the cough centre. N, cortical input; VN,
vagus nerve.

9. Anatomical representation of neural pathways for cough
Cough receptors (shown in red color) at the airway bifurcations, in the larynx
and at the distal esophagus, link to cough afferents through the vagus and
superior laryngeal nerves to the cough centre and cerebral cortex.
Efferent pathways coordinate the muscle response that leads to a cough.

10. The cough reflex
Cough stimulus
Cough centre
Cough “muscles”
Cough
Central modulation

11. Cough clears the larynx, trachea, and
large bronchi of secretions such as
mucus, noxious substances, foreign
particles, and infectious organisms.
Chung K F& Pavord I D . Lancet 2008; 371: 1364–74

12. Coughing in children can be distressing and
has a major impact on
 child’s sleep
 school performance
 ability to play
 other family members’ sleep
 disruptive for school teachers
 Considerable parental anxiety is generated
in families with a child with problem
coughing.
Cornford et al. Fam Pract 1993;10:193–6.
Kai J. BMJ 1996;313:983–6.

13. However, concerns of parents presenting to
general practitioners for their children's
cough can be extreme as fear of child
dying or chest damage.
Cornford et al. Fam Pract 1993, 10:193-196.
Davies et al. Arch Dis Child 1998, 79:465.

14. Classification of pediatric cough
Pediatric cough can be classified in several
ways, based on:
 Time frame
 Etiology
 Characteristics (moist vs dry).
Chang AB, Asher MI. J Asthma 2001, 38:299-309.
Bush A. Pulm Pharmacol Ther 2002,15:309-315.

15. A chronic moist cough is always
abnormal and represents
excessive airway secretions.
Chang Ab et al. Respiratory Research 2005, 6:3.

16. A chronic dry cough however may represent a
dry phase of an otherwise usually moist cough
or airway secretions too little to influence
the cough quality .
Chang AB, et al. Arch Dis Child 1997, 77:331-334.
Chang AB, et al. Am J Respir Crit Care Med 1997, 155:1935-1939

17. Acute cough
A recent onset of cough lasting < 3 weeks.
Prolonged acute cough
Clearly there is a ‘‘grey’’ area between acute and
chronic cough, sometimes called ‘‘subacute
cough’’.
An example of such a situation would be a child
with pertussis or postviral cough whose cough
may be slowly resolving over a 3–8-week
period.
Shields et al. Thorax 2008;63:1-15.

18. Recurrent cough
 A recurrent cough without a cold is taken as
repeated (>2/year) cough episodes, that
each last more than 7–14 days.
Sherrill et al. Respir Med 2005;99:1377–85.
Chang et al. Am J Respir Crit Care Med 1997;155:1935–9.
 If the periods of resolution are short, frequently
recurrent cough will be difficult to distinguish from
persistent chronic cough.
Shields et al. Thorax 2008;63:1-15.

19.  The infections may occur ‘‘back to back’’
and give the impression of a chronic
persistent cough.
 However, these children should experience
short breaks in their symptoms in between
infections.

20. Chronic cough
 There are no studies that have clearly defined
when cough should be defined chronic or
persistent.
 As studies have shown that cough related to
ARIs resolves within 1 to 3 weeks in most
children
Hay AD, Wilson AD. Br J Gen Pract 2002, 52:401-409.
Hay ADet al. Fam Pract 2003, 20:696-705
it would be logical to define chronic cough as
daily cough lasting >4 weeks.
Hay A D, et al.Fam Pract 2003;696-705

21.  Cough that lasts more than 4 weeks in children
younger than 14 years of age or more than 8
weeks in adolescents and adults 14 years of age
and older is considered to be chronic.
 Such chronic cough is responsible for up to 38
percent of pulmonary outpatient visits.
Irwin et al. Am Rev Respir Dis 1981;123(4 Pt 1):413-7. PMID: 7224353.
Irwin et al. Am Rev Respir Dis 1990;141(3):640-7. PMID: 2178528.

22. Data from questionnaire studies suggest
that as many as 10% of preschool and
early school aged children have chronic
cough without wheeze at some time in
their lives.
Yi. Bulletin 39 November 2004 MITA (P) No: 275/05/2003

23.  Parental smoking is a known factor for
chronic cough.
 If both parents smoke, up to 50% of children
below 11 years of age may have chronic
cough.
Yi. Bulletin 39 November 2004 MITA (P) No: 275/05/2003

24. Unlike cough in adults, pediatric cough has also been
classified into specific and non-specific cough (with an
overlap) for practical reasons .
Chang AB: Causes, assessment and measurement in children. In Cough: Causes, Mechanisms and Therapy Edited by:
Chung FK, WiddicombeJG, Boushey HA. London: Blackwell Science; 2003:57-73.

25. What is 'normal' or expected?
Normal children without a preceding upper respiratory
infection in the last 4 weeks have up to 34 cough
epochs per 24 hours.
Munyard P, Bush A. Arch Dis Child 1996, 74:531-534.
In another study, 0–141 cough epochs/24 hours
(median 10) were recorded in 'controls‘ (these children
were considered well by parents and attending school
and were age, gender and season matched .
Munyard P, Bush A. Arch Dis Child 1996, 74:531-534.
Cough in this situation is termed 'expected cough'.

26. Non-specific cough
Chronic dry cough in the absence of specific
pointers in the history and examination
is termed 'non-specific cough' or 'isolated
cough', ie cough is the sole symptom.
Chang AB, et al. Arch Dis Child 1997, 77:331-334.
Chang AB, et al. Am J Respir Crit Care Med 1997, 155:1935-1939

27. In non-specific cough, the etiology is ill
defined and the majority are related to post
viral cough and/or increased cough receptor
sensitivity.
Chang AB, et al. Arch Dis Child 1997, 77:331-334.
Chang AB, et al. Am J Respir Crit Care Med 1997, 155:1935-1939.

28. Specific cough
A specific cough is one in which there is
a clearly identifiable cause.
Shields et al. Thorax 2008;63:1-15.

29. Non-specific isolated dry coughing in an
otherwise well child should be
differentiated from those with more serious
conditions. ‘‘Red flag’’ alert
symptoms/signs include:

30. Pointers to the Presence of
Specific Cough
 Auscultatory findings
 Cardiac
abnormalities
 Dyspnea ,tachypnea
 Chest wall deformity
 Daily productive
cough
 Hemoptysis
 Feeding difficulties
 Digital clubbing
 Chest pain
 Exertional dyspnea
 Hypoxia/cyanosis
 Immune deficiency
 Neurodevelopmental
 Recurrent pneumonia
 Failure to thrive

31. Digital Clbbing

32. Because cough receptors
also reside in the
 pharynx
 paranasal sinuses
 stomach
 external auditory canal
the source of a persistent cough may need to
be sought beyond the lungs

33. Differential diagnoses of chronic cough during
infancy (in descending order of likelihood).
 Gastro-esophageal reflux disease
 Infection
 Congenital malformation
 Congenital heart disease
 Passive smoking
 Environmental pollution
 Asthma
Chow and Ng:Singapore Med J 2004 45(10) ,462-469.

34. Differential diagnoses of chronic cough during
early childhood (in descending order of likelihood).
 Post-viral airway hyper-responsiveness
 Asthma
 Passive smoking
 Gastro-esophageal reflux disease
 Foreign body
 Bronchiectasis
Chow and Ng:Singapore Med J 2004 45(10) ,462-469.

35.  upper airway cough syndrome (UACS) due to
a variety of rhinosinus conditions, which was
previously referred to as postnasal drip
syndrome (PNDS)
 asthma
 GERD
Irwin et al. Am Rev Respir Dis 1981, 123:413-417.
Pratter et al. Ann Intern Med 1993, 119:977-983.
Poe et al. Chest 1989, 95:723-728.
Mello et al. Arch Intern Med 1996, 156:997-1003.
Palombini et al. Chest 1999,116:279-284.

36. The term UACS includes cough
secondary to
 allergic rhinitis
 nonallergic rhinitis
 nonallergic rhinitis with eosinophilia
 postinfectious rhinitis
 bacterial sinusitis
 allergic fungal sinusitis
 abnormal anatomy causing rhinitis
 chemical or occupational irritant rhinitis
 rhinitis medicamentosa
 rhinitis of pregnancy
.
Rank et al. Ann Allergy Asthma Immunol. 2007;98:305–313.

37. Darkening of the lower eyelids as a result of
suborbital edema (allergic shiner)

39. Differential diagnoses of chronic cough
during late childhood (in descending order
of likelihood).
 Asthma
 upper airway cough syndrome (UACS
 Smoking
 Pulmonary tuberculosis
 Bronchiectasis
 Psychogenic cough
Chow and Ng:Singapore Med J 2004 45(10) ,462-469.

40. The three dominant etiologies
 Upper airway cough syndrome (UACS)
 Asthma
 GERD

41.  In four prospective studies this triad of
diagnoses was so ubiquitous that in 92
to 100% of patients who had normal
chest roentgenogram findings.
Irwin et al. Am Rev Respir Dis 1981, 123:413-417.
Palombini et al. Chest 1999,116:279-284.
Smyrnios et al Chest 1995, 108:991-997.
Corrao et al. N Engl J Med 1979, 300:633-637

42.  The presence of one, two, or even all three
of these conditions proved to be the
etiologic explanation for chronic cough .
Irwin et al. Am Rev Respir Dis 1981, 123:413-417.
Palombini et al. Chest 1999,116:279-284.
Smyrnios et al Chest 1995, 108:991-997.
Corrao et al. N Engl J Med 1979, 300:633-637

43. Asthma

44. A Lot Going On Beneath The Surface
Airway
inflammation
Airflow
obstruction
Bronchial
hyperresponsiveness
Symptoms

45. Cough and Asthma
Cough is a major symptom of asthma
 ‘cough variant asthma (CVA)
 Cough predominant asthma
 cough that persists despite standard
therapy with inhaled corticosteroids and
bronchodilators
Niimi et al. Pulm Pharmacol Ther 2009; 22:114-20.
Niimi A. Clin Pulm Med 2008; 15: 189-96.

46. Features suggestive of cough-variant
asthma include:
 Presence of cough between episodes of upper
respiratory tract infections associated with known
asthma triggers
 Cough that is typically worse in the early hours of the
morning when the child is asleep
 Cough that occurs after playing or exercising
 Personal atopy or strong family history of atopy
 No evidence of alternative diagnosis
 Response to a therapeutic trial of asthma medication.

47. Respiratory Infections
 Viral upper respiratory tract infections
may occur “back to back” and give the
impression of a chronic persistent cough.
 Children may have up to 10 upper
respiratory tract infections in a year.

48. In the ‘‘pertussis-like’’ illnesses the
cough is often spasmodic and choking
in nature, and may result in the
classical whoop or in vomiting.
de Jongste J C , Shields M D. Thorax 2003;58;998-1003

49. A child displaying pertussis
symptoms

50. A child displaying pertussis symptoms

51. Child with Pertussis

52. Some lower respiratory tract infections may also
cause prolonged cough, including:
 RSV
 pertussis
 chlamydial
 T B

53. Gastro-esophageal Reflux Disease
 GER occurs in up to 65% of normal
babies
 abnormal symptoms and signs that
warrant a diagnosis of GERD occur in
approximately one in 300 infants.

54. Gastro-esophageal Reflux Disease
 Regurgitation with poor weight gain
 Fussiness, discomfort and crying during
feedings
 Apnea and cyanosis in infants
 Stridor or wheezing
 Aspiration or recurrent pneumonia
 Neck tilting or arching in infants (Sandifer’s
syndrome)
 Hemetemesis and iron deficiency anaemia

55. Other Causes of Chronic Cough
 Foreign body aspiration
 dysfunctional swallowing
 congenital anomalies
 benign tumours, malignancies
 immunodeficiencies
 primary ciliary dyskinesia.

56. FBAO: Signs/Symptoms
 Suspect in any previously well, a febrile
child with sudden onset of:
 Respiratory distress
 Choking
 Coughing
 Stridor
 Wheezing

57. Inhalation of Foreign Body
 Cough was present in 70% of patients
 decreased breath sounds (53%)
 wheezing (45%)

58.  A history of a choking episode was
reported in 32% of patients
 when families were questioned in more
detail the rate increased to 51%.

60. In a, right lower lobe consolidation, bronchiectasis, and a foreign
body lodged in the bronchus intermedius (arrow) are
seen.
In b, subcarinal and right hilar lymphadenopathy, right lower
lobebronchiectasis, and a foreign body lodged in the bronchus
intermedius (arrow) are visible.

61. cystic fibrosis

62. Cystic fibrosis chest physiotherapy

63. Mucociliary Escalator
 Muscus-
Traps particles
 Cilia-
Move particles up
toward pharynx

64. Primary ciliary dyskinesia
(PCD)
 otitis media
 Chronic sinusitis
 Recurrent pneumonia
 Situs inversus in 50%
 Bronchiectasis in 30%
 Kartagener’s syndrome in which there is a defect in
the dynein arms of the cilia. Patient also exhibit
dextrocardia, congenital heart disease, and infertility.

65. Axial CT image showing situs inversus.

66. Psychogenic Cough
 School aged children.
 The child is often a high achiever;
family stress
 Fixed timing but disappears during
sleep and when distracted.
 Diagnosis by observation and exclusion
of other causes.

67. Management of Chronic
Cough

68. Goals of Treatment
SLEEP
LEARN
PLAY

69.  To recognize its cause is not always an easy
task.
 Where possible, the clinician should avoid
treatment based on symptoms only which
often only serves the purpose to reassure the
parents.

70. Most children with cough due to a simple
upper respiratory tract infection will not
need any investigations
The absence of fever, tachypnea and chest
signs appear to be most useful for ruling out
future complications in children with cough
in primary care.

71. History:
 Doctors should assess the importance
of the symptom, its place in, and the
repercussions on, the life of the child.
 Doctors should also inquire about the
parents’ anxieties and expectations.

72. History taking should include asking
about signs and symptoms of the most frequent
etiologies:
 Upper airway cough syndrome (UACS)
 asthma
 respiratory tract infections
 gastro-oesophageal reflux.
 Environmental factors such as passive
smoking exposure

73. Clinical examination should includ
 respiratory rate
 signs of dyspnea
 signs of atopy
 height, weight
 temperature
 ear, nose and throat examination
 chest auscultation
Stoffelen H, De scampheleire L, Van Peer W. Asthma bij kinderen. Aanbeveling
voor goede medisch Praktijvoering. WVVH. 1999. berchem 26 p, www.wvvh.be
National Institutes of health, national heart lung and blood institute. Guidelines
for the diagnosis and management of asthma, expert panel report 2.1997. http://www.nhlbi.nih.gov/

75. Investigations

76. Suspicion of infection:
 Serology for M pneumoniae and
serology plus PCR for B pertussis could
be useful
 if there is a suspicion of pneumonia, a
chest X-ray should be performed
 There is no evidence of the usefulness
of determining the CRP concentration or
leukocyte count in chronic cough.

77. Suspicion of asthma
Asthma Predictive Index (API)

78. Suspicion of asthma
Spirometry should be done if the child is
older than 5 years
Diagnostic trial: some authors and
guidelines recommend trying inhaled ß-
agonists or ICS and assessing
responsiveness.

79. Suspicion of sinusitis:
Sinus radiography:
- before the age of six years, radiography
is unnecessary(88% of X-rays are
positive if there is a clinical history of
sinusitis).

80. Suspicion of gastro-esophageal reflux:
pH-monitoring is the most useful test to
assess the temporal association
between reflux and cough.

81. Chest radiography
 There is not sufficient evidence to
recommend chest radiography in all
cases.
 It can be useful when specific lung
pathology is suspected or in unclear
cases which do not improve.

83. Recommendations

86. 4. Children with chronic productive
purulent cough should always be
investigated to document the presence
or absence of bronchiectasis and to
identify underlying and treatable
causes such as cystic fibrosis and
immune deficiency.

87. 6. In children with nonspecific
cough, cough may
spontaneously resolve, but
children should be reevaluated
for the emergence of specific
etiologic pointers.

88. 7. In children with nonspecific cough and
risk factors for asthma, a short trial (ie, 2
to 4 weeks) of beclomethasone, 400
μg/d, or the equivalent dosage with
budesonide maybe needed.
 However, most children with nonspecific
cough do not have asthma. In any case,
these children should always be
reevaluated in 2 to 4 weeks.

89. 9.In children with cough, cough
suppressants and other OTC cough
medicines should not be used as
patients, especially young children, may
experience significant morbidity and
mortality.

90. 10. In children with nonspecific cough,
parental expectations should be
determined, and the specific concerns
of the parents should be sought and
addressed.

91. 11. In all children with cough,
exacerbating factors such as ETS
exposure should be determined and
interventional options for the cessation
of exposure advised or initiated.

92. 12. Children should be managed
according to the studies and guidelines
for children (when available), because
etiologic factors and treatments in
children are sometimes different from
those in adults.

93. 13. In children < 14 years of age with
chronic cough, when pediatric-specific
cough recommendations are
unavailable, adult recommendations
should be used with caution.

94. The FDA issued a warning for parents and
health workers against the use of OTC
products for cough and common colds in
infants and children under 2 years of age
because of serious side effects and the
potential danger to life that may arise as a
result of their use in children
American Academy of Pediatrics. Pediatrics 1997, 99:918-920.
Irwin etal. American College of Chest Physicians (ACCP):Chest 2006, 129:1S-23S.

95. Cough is a symptom and not a
diagnosis.
Always look for the underlying
cause for the chronic cough.

96. The younger the child the lower is the
threshold for referral and further
investigations.