The coughing child 2015 with sound v3

1. THE COUGHING
CHILD
Dr Mark Rosenthal.
Royal Brompton
Hospital

2. www.drmarkrosenthal.com

3. Medical student features of a pain
 Site
 Sort
 Severity
 Onset
 Duration
 Periodicity
 Aggravating and relieving factors
 Time off work/school

4. Its all in the history
 Age of child
 Age of onset
 Acute vs Chronic (definition of chronic)
 Episodic vs continuous
 Dry vs wet
 Associated symptoms eg wheeze

5. Not everything
that coughs is
asthma!

7. Paediatrics is just pattern recognition like everything else in life!

8. Its all in the history
Age of onset
 Age of Child
 Acute vs Chronic (definition of chronic)
 Episodic vs continuous
 Dry vs wet
 Associated symptoms eg wheeze

9. Age of Onset
 Birth = Congenital
 2 weeks = Gastroesophageal reflux, RSV,
(laryngomalacia), Cystic fibrosis, foreign body
from helpful sibling.
 4 months plus all above plus everything else
 Always challenge the answer ‘from birth’ if
the question ‘when did this all start?’

10. A word about........
 Well child developing normally starts a wet
cough at around one month of age.
 Intermittent - can occur day or night. Child
not particularly unwell
 Gets treated for ‘chest infections’ without
benefit
 The diagnosis may be.................?

11. ASPIRATION FROM ABOVE!!
 Always one to consider even if neurologically
completely normal as more common than
realised butVERY common in Down syndrome
 Almost always a maturational swallowing
problem
 More likely if additional symptoms of eye
watering with feeds or a ‘wet voice’ after a feed.
 Speech and language people vv helpful
 Feed thickeners is the treatment
 95% grown out of by age 4.5 years much older
for Downs

12. Its all in the history
Age of child
 Age of onset
 Acute vs Chronic (definition of chronic)
 Episodic vs continuous
 Dry vs wet
 Associated symptoms eg wheeze

13. Age of child
 In relation to age of onset – measure of
severity. Get better image of pattern

14. Its all in the history
 Age of child
 Age of onset
Acute vs Chronic (definition
of chronic)
 Episodic vs continuous
 Dry vs wet
 Associated symptoms eg wheeze

15. Acute versus Chronic
 ‘It started at 6-15pm on the 4th January’

16. A word about foreign bodies
 The number of legal cases is epic.
 A normal chest x-ray does notexclude one
 ANY history of objects in mouth/choking etc
are assumed to be correct.

17. Acute versus Chronic.....2
 Human Rhinovirus leading to coughing when
aged 1 has very low risk of asthma aged 7
years
 Human Rhinovirus leading to coughing aged
3 years has much higher risk of child being
asthmatic aged 7 years

18. Acute vs Chronic....3
Acute persistent
37% of children coughing
Had serological evidence of
B Pertussis esp if whooping,
Vomiting or producing
sputum

19. Its all in the history
 Age of child
 Age of onset
 Acute vs Chronic (definition of chronic)
Episodic vs continuous
 Dry vs wet
 Associated symptoms eg wheeze

20. Key Symptom Patterns

21. Its all in the history
 Age of child
 Age of onset
 Acute vs Chronic (definition of chronic)
 Episodic vs continuous
Dry vs wet
 Associated symptoms eg wheeze

22. Dry Vs Wet
 Wet = upper or lower airway
secretions/sepsis.
 Consider post nasal drip – DOESTHE CHILD
SNORE?!!
 CF despite screening still occurs.
 Dry – more likely asthma, gastroesophageal
reflux

23. Gastroesophageal reflux
 Much more common than is realised.
 Not required to vomit
 Getting a history can be difficult
 A trial of treatment is best way of making
diagnosis – OmeprazoleTWICE a day

24. About 50% of children chronic unexplained cough
had reflux related cough episodes mainly in the day
without gastrointestinal symptoms

25. Its all in the history
 Age of child
 Age of onset
 Acute vs Chronic (definition of chronic)
 Episodic vs continuous
 Dry vs wet
 Associated symptoms eg wheeze

26. A few home truths!
 Not everyone that ‘wheezes’ has wheezing.
 Not everyone with wheezing has asthma.
 Not everyone with asthma has wheezing.

27. Not everyone that ‘wheezes’ has
wheezing.
 Only 3 respiratory noises:
 Stridor – Inspiratory – from low pitch to
high pitch
 Wheezing – Expiratory - from high pitch to
low pitch
 Stertor – A gargling sound both inspiratory
and expiratory.
 Parents know 2 words: Croup and
wheezing!

28. SO………
 NEVER accept the parents’ word that their
child is wheezing until you have checked it
out.
 The killer question is: ‘Tell me what you
mean by wheezing?’

29.  Parents ability to match the
wheezing video to their doctor
observed wheezing child =
 50% ie tossing a coin (Saglani
2005)

30. The 10 year old chorister
 3 months ago, a previously healthy child (who
may have had a trivial asthma aged 7 years)
following a mild viral illness with mild cough
has progressed to an increasingly severe
honking cough that was heard x 3 during the
consultation and this has preventing him
singing.
 What is the ONE question you ask that gives
the diagnosis?

31. It is November.............
 A boy presents with increasingly difficult to
control asthma for the past 2 months.
 He was known to you for 3 years with mild
asthma needing 12 months inhaled steroids
at low dose, no casualty presentations in the
past and for previous 18/12 had used a
bronchodilator only about 4 times a year.
 How old is he and what happened 2 months
ago?

32. The 16 year old tennis player
 Talented female player who has started at a full time
tennis academy in Hertfordshire.
 Gradually notices that during the group warm up
exercises that involves running as fast as possible
around tennis court that after 4 goes in a warm up
develops an increasing sense of constriction in her
upper chest, finds it impossible to breathe and fears
she will collapse. Recovers after about 10 minutes
 Over a 6 week period coming on earlier and earlier
during the warm up and has now started occurring
during practice matches.
 What do you expect to find on examination?

33. The 10 year old chorister
 3 months ago, a previously healthy child (who
may have had a trivial asthma aged 7 years)
following a mild viral illness with mild cough
has progressed to an increasingly severe
honking cough that was heard x 3 during the
consultation and this has preventing him
singing.
 What is the ONE question you ask that gives
the diagnosis?

34. It is November.............
 A boy presents with increasingly difficult to
control asthma for the past 2 months.
 He was known to you for 3 years with mild
asthma needing 12 months inhaled steroids
at low dose, no casualty presentations in the
past and for previous 18/12 had used a
bronchodilator only about 4 times a year.
 How old is he and what happened 2 months
ago?

35. The 16 year old tennis player
 Talented female player who has started at a full time
tennis academy in Hertfordshire.
 Gradually notices that during the group warm up
exercises that involves running as fast as possible
around tennis court that after 4 goes in a warm up
develops an increasing sense of constriction in her
upper chest, finds it impossible to breathe and fears
she will collapse. Recovers after about 10 minutes
 Over a 6 week period coming on earlier and earlier
during the warm up and has now started occurring
during practice matches.
 What do you expect to find on examination?

36. Ticking the Tic box
 The only relevant question is:
 ‘Does it occur when X is in bed at night
ASLEEP?’

37. Summary
 Take a history
 Take a better history!!
 Do they snore?
 Do they aspirate?
 Not everything is asthma
 Beware foreign bodies
 Trials of treatment eg
asthma/antireflux/montelukast should be for
a maximumof one month and then
reassessed

38. Thank you for listening
and have good morning!
www.drmarkrosenthal.com