COUGH

1. APPROACH TO COUGH IN
CHILDREN
DR. S.SOWNDARYA
1sy year PG DCH
Coimbatore child trust hospital

2. Introduction
• Cough is one of the most important
protective reflexes,
• contributes significantly to the innate
immunity of the respiratory system by
enhancing mucociliary clearance.
• Cough is under both voluntary and
involuntary control.

3. Pathophysiology
• Cough receptors - vagal afferent nerves
located in the
• larynx,
• pharynx
• tracheobronchial tree,
• Extrapulmonary sites - external ear
can trigger cough due to stimulation of the
auricular branch of the vagus nerve .

4. Pathophysiology
• cough center in the medulla oblongata, which
then triggers the sequence of events that
constitutes a cough.
• Three sequential phases:
inspiratory, compressive and expiratory.

5. Pathophysiology
• cough efficiency -adequate airway caliber (airway
narrowing decreases efficiency, e.g., malacia),
mucus properties and respiratory muscle
strength
• Given that cough is a protective reflex, it is
crucial not to suppress it without identifying and
treating its underlying cause.
• The sensitivity of the cough receptors are
modulated by disease state.

7. • Up-regulation of cough receptors - after viral
URTI, asthma, gastroesophageal reflux disease
(GERD), and treatment with ACEi. This causes
cough to be triggered through relatively non-
specific provocation.
• Cough undergoes considerable developmental
phases; it can be elicited in 10% of 27-week
gestational age preterm infants and up to 90%
of full-term infants

8. Duration of cough
• Most cases of acute cough in children are
associated with viral URTI and do not require
specific diagnostic evaluation.
• Acute: cough lasting less than 4 weeks.
• Chronic: cough lasting more than 4 weeks.

9. Etiology of cough
• Normal or expected cough: the occasional daily cough,
as described above, or a mild cough that has an
obvious cause (e.g., after URTI) and does not require
further intervention.
• Specific cough: cough associated with other symptoms
and signs suggestive of an underlying problem
• Non-specific cough: dry cough in the absence of an
identifiable respiratory disease of known etiology. The
majority of cases are due to non-serious etiology
(e.g., post-viral cough and/or increased cough receptor
sensitivity) and may spontaneously resolve.

12. Quality of cough
Classically recognized cough sounds:

13. Wet vs. Dry Cough
• dry cough can be converted to wet cough when airway
secretions increase.
• young children rarely expectorate sputum, so wet
cough, rather than productive cough, is the preferred
term.
• Wet cough -mucous hypersecretion or impaired
mucociliary clearance
• dry cough -airway irritation or inflammation or a non-
airway cause
Wet cough warrants detailed investigation whenever it
becomes chronic or associated with other
manifestations (e.g., failure to thrive or clubbing).

14. Assessment of cough in children
• duration,
• quality,
• triggers,
• progress
• diurnal/seasonal variation of the cough, associated
symptoms
• neonatal history,
• family history,
• environmental exposures, in particular second
hand smoking (or other irritants e.g., wood smoke
exposure), medications and allergy history.

15. Physical examination
• general well-being of the child
• vital signs and growth parameters,
• RS(including ENT) examination,
• nutritional status
• examination for certain physical signs (e.g.,
noisy breathing and clubbing).

16. Investigations
ACUTE COUGH:
• viral/post-viral URTI
do not require further investigation.
• CXR – if signs indicate lower respiratory tract
involvement, progressive nature, hemoptysis
or features of an undiagnosed chronic
respiratory disorder.
• Bronchoscopy If an inhaled foreign body is
suspected

17. Chronic cough
• CXR
• Lung function test,
• Bronchodilator responsiveness
• Individualized based on the clinical presentation of
each patient
• Feeding/swallowing assessment for aspiration,
• Immune work-up for immunodeficiency,
• Sweat chloride test for cystic fibrosis,
• CT scan for bronchiectasis, bronchoscopy for inhaled
foreign bodies and/or to obtain bronchoalveolar
lavage).

18. Chronic cough
• wet cough-sputum.
• Allergy testing (skin prick or RAST specific
testing
• A therapeutic trial of asthma medication can
be used as a diagnostic tool for chronic cough
in young children, when there is a lack of
other objective indicators of asthma.

19. Management of cough in children
• Goal- identify an underlying cause of cough in children.
• Majority - the etiology is related to URTI and requires
only supportive measures (e.g., antipyretics, good
hydration, and saline washes).
• Over-the-counter antitussives, antihistamines and
decongestants are as effective as placebo for acute
cough and have the potential to cause adverse effects –
avoid < 2 years of age.
• Intranasal steroids - allergic rhinitis presenting with
cough during pollen season.

20. • Antibiotics – AVOIDED in acute cough caused by viral URTI.
• Pertussis - macrolide antibiotics should be prescribed early
(1–2 weeks of illness).
• Specific causes of acute cough (e.g., asthma, bronchiolitis,
croup, and community-acquired pneumonia) should be
managed based on the evidence-based guidelines specific
for such entities.
• Honey products are a natural and safe therapeutic option
with a slight effect that can be considered for acute cough
following URTI in children >2 years of age

21. Management of chronic cough
• standardized algorithm in the management of
children with chronic cough improves clinical
outcomes
• (earlier cough resolution and improved parental
quality of life).
• Foreign body inhalation should always be
considered in children with chronic cough.
• This is important, even if a chocking episode was
not witnessed, especially if the cough onset was
clearly abrupt.

22. Protracted(i.e. persistent) bacterial
bronchitis
• common cause of chronic cough in children
• defined as a chronic wet cough with positive
BAL (Streptococcus pneumoniae, Haemophilus
influenzae, and Moraxella catarrhalis)
• that resolves with antibiotic therapy
• Other possible diagnoses (e.g., asthma) ruled
out.

23. • For these children, a trial of prolonged
antibiotics (typically amoxicillin and
clavulanate for 2–4 weeks) is recommended.
• should be followed at the end of the
therapeutic trial for assessment of response
and consideration of an alternative diagnosis.

24. HEALTHY CHILDREN
NON-SPECIFIC CHRONIC
• cough, “watchful observation” with follow-
up assessment (in 6–8 weeks) is acceptable.
• Parental assurance is indicated, self-limiting.

25. HABIT (PSYCHOGENIC) COUGH
• can benefit from psychotherapy, such as
suggestion and/or behavioral therapy.
• Organic causes to be RULED OUT.

28. REFERRAL FOR SUB-SPECIALIST ADVICE
• Chronic wet cough unresponsive to antimicrobial therapy.
• Specific-cough indicating an underlying disease
(e.g., cystic fibrosis or primary ciliary dyskinesia).
• Uncertain diagnosis of chronic non-specific cough.
• Partially resolved, prolonged (>3 months)
• recurrent protracted bronchitis (>2 times/year).
• Suspicion of foreign body inhalation.
• Suspicion of congenital/developmental defect.
• Chronic cough associated with persistent hypoxemia.

29. Reference
• https://www.ncbi.nlm.nih.gov/pmc/articles/P
MC6372369/#:~:text=In%20otherwise%20hea
lthy%20children%20with,healthy%20children
%20are%20self%2Dlimiting.
• Nelson’s textbook of pediatrics 21st edition.