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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Marufa Marium, M.B.B.S[2]

Synonyms and Keywords: Cough in kids

Overview

Cough is a common complaint of the pediatric population of the outpatient department. It is a natural reflex by which foreign and infectious particles are cleared through an involuntary expulsive force of air by the dynamic mechanism of respiratory airways. The word 'Cough' is derived from the 14th century Dutch word 'Kochen' and the high middle German word 'Kuchen'. Cough is classified under several categories. For example, duration of the complaint, nature or quality, anatomical location, etiology and grades of coughs. Stimulation to cough receptors provokes sensations of coughing through the afferent pathway via the vagus nerve, central respiratory centers in the upper pons and medulla, and efferent pathways via the phrenic and vagus branches. Differential diagnoses of cough are evaluated through identifying specific etiology, presenting symptoms, detailed history and findings of physical examination, laboratory, and imaging investigations. Some of the causes are emergently managed to reduce the mortality of a child.The mainstay of therapy for cough is supportive. Antihistamine, antitussive medications and nasal decongestant are provided for alleviating symptoms of acute cough. Allergic conditions are treated with steroids.

Historical Perspective

  • The word cough was first derived from the middle English word 'Coughen' or old English 'Cohhian' which was primarily composed of the middle Dutch 'Kochen' and the high middle German 'Kuchen', in early 14th century.

Classification

  • Cough in children may be classified or defined according to the duration of presenting complaints, quality and sound, and causes of cough into several groups.[1]:
  • 1 Duration of Presenting complaints: According to the duration of cough, it can be sub-classified into three categories:
  • 2. Nature or quality and sounds: According to the quality and sound, the cough can be sub-classified in to following categories:
    • Dry or Hacking or Nonproductive.
    • Wet or productive cough.
    • Staccato or short repetitive cough.
    • Whooping or paroxysmal violent or spasmodic cough.
    • Barking cough: Brassy barking or Honking barking.
    • Phlegmy cough.
    • Burning cough.
  • 3. Causes of Cough: Based on the causes, a cough is subdivided into following three subgroups:
    • Specific cough.
    • Nonspecific cough.
    • Expected cough or Normal cough.
  • 5. Grades of cough: Cough can be graded into four main sub categories:[2]
    • Eutussia or Normal.
    • Hypertussia or Sensitized.
    • Hypotussia or Desensitized.
    • Dystussia or Pathological.
    • Atussia or Absent.

Cough in children can also be classified under infectious (Bacterial, Viral, fungal, Parasitic) or non-infectious categories broadly.

Pathophysiology

 
 
 
Mechanical and chemical stimulation of cough receptors (RARs or Rapidly adapting receptors, C fibers or slowly adapting receptors) in Respiratory airways
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Afferent pathways: Sensory nerve fibers via Vagus Nerve from ciliated columnar epithelium of upper airways, cardiac and esophageal branches from diaphragm send impulse to central cough center
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Central cough center in upper brain stem medulla and pons send impulse of sequence of phases (Inspiratory, Compressive, Expiratory) for constituting cough
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Efferent pathways: The nucleus retroambigualis sends impulse via phrenic and spinal motor nerves to diaphragm and abdominal and respiratory muscles, the nucleus ambiguous sends impulse to larynx by laryngeal branches of vagus nerve
 
 
 

Causes

Causes of cough in children according to duration[4][5][6]:

 
 
 
 
 
 
 
 
Cough
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Acute(<3 weeks) •Common Cold
Allergic Rhinitis
Bronchitis
Bronchiolitis
Asthma
Whooping Cough
Influenza
Croup or Tracheolaryngobronchitis
Pneumonia
Irritation by smoking
Foreign Body
GERD
 
 
 
 
Subacute(3-8 weeks) •Whooping Cough or Pertussis
•Post infectious Cough
Bacterial Sinusitis
Asthma
 
 
 
 
Chronic(>8 weeks) •Upper Airway Cough Syndrome
Asthma
Bronchiectasis in Cystic fibrosis and Kartagener Syndrome
Chronic sinusitis
Malacia
•Foreign Body
Nonasthmatic eosinophilic bronchitis
•Respiratory environmental toxins

According to quality and sound of cough in children, the causes can be classified according to the following chart:

 
 
 
 
 
 
 
 
 
 
 
 
Dry or Hacking or Nonproductive
 
Sinusitis, Tonsillitis, Pharyngitis, Allergic Rhinitis, GERD, Asthma, Environmental exposure to irritants(pollen, dust, mites, smoke), Post infectious cough.
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Wet or productive cough
 
Cystic fibrosis, Bronchiectasis, Bronchiolitis, Tuberculosis, Rhinitis, Postnasal drip, Pneumonia, Emphysema, Acute bronchitis, Asthma
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Causes of Cough based on Nature or quality and sound
 
 
 
 
Staccato or short repetitive cough
 
Chlamydia pneumonia
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Whooping or paroxysmal violent or spasmodic cough
 
Pertussis
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Barking cough
 
Brassy barking: Croup, Tracheomalacia, Laryngitis, Tracheitis
Honking barking: Psychogenic cough , Tourette syndrome (habit cough)
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Stridor
 
Viral Croup, Epiglottis, Bacterial tracheitis, Retropharyngeal and peritonsilar abscess
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Burning cough
 
Bacterial Bronchitis, Irritants
 
 
 
 
 
 

Based on anatomical location the causes of cough in children can be demonstrated in the following chart:

 
 
 
 
 
 
 
 
 
 
 
 
Nose and Paranasal sinuses
 
Rhinitis, Foreign Body, Sinusitis, Nasal polyp, ppHypertrophied inferior turbinate]]
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Pharynx
 
Pharyngitis, Foreign Body, Irritants
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Larynx
 
Laryngitis, Epiglottis, Tonsillitis, Laryngomalacia, Subglottic stenosis, Foreign body
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Trachea and Bronchi
 
Tracheitis, Croup, Bronchiolitis, Bronchiectasis, Bronchitis, Cystic fibrosis
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Causes based on anatomic location
 
 
 
 
Pulmonary parenchyma
 
Pneumonia, Tuberculosis, Environmental toxin, Respiratory distress syndrome, Aspiration syndrome, Hypersensitivity Pneumonitis, Connective tissue disease, Alveolar capillary dysplasia, Neuroendocrine cell hyperplasia of infancy, Medications, Mutations causing surfactant dysfunction, Emphysema
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Pleura
 
Pleurisy, Pneumothorax, Hemothorax, Parapneumonic effusions, Pleural tuberculosis, Congenital hydrothorax and chylothorax
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Mediastinum
 
Mediastinitis, Mediastinal Tuberculosis, Thymoma, Thymic hyperplasia, Thymic carcinoma, Neuroblastoma, Ganglioneuroma, Non Hodgkin lymphoma, Sarcoma, Mature teratoma, Endodermal sinus tumor, Hemangioma, Wilms tumor, Lymphangioma
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Heart and blood vessels
 
Congenital heart disease, Myocarditis, Heart failure, Cardiomyopathies, Wegener granulomatosis, Valvular heart disease, Vasculitis, Arteriovenous malformation
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
External ear and Tympanic membrane
 
Otitis media and externa, Impaction of foreign body, wax, Myringitis
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Esophagus
 
GERD, Tracheoesophageal Fistula
 
 
 
 
 
 

Differentiating Cough from other Diseases

Organ system Diseases Clinical manifestations Diagnosis Other features
Symptoms Physical exam
Onset Duration Productive cough Hemoptysis Weight loss Fever Dyspnea Physical Examination Lab findings Imaging PFT Gold standard
Respiratory Upper airway diseases Epiglottitis[7][8] Abrupt or acute
  • 12−24 hours
+ +
  • Elevated white blood count in CBC
  • Blood culture may show bacterial growth
  • Epiglottal culture in intubated patients may show bacterial growth
  • Enlarge epiglottis (>8 mm), loss of vallecular air space and distended hypopharynx as known as 'Thumb print' sign on lateral neck X−ray may be helpful
  • Normal function
Croup[9] Acute
  • 3−5 days
+ + +
  • Clinical diagnosis.
  • Laboratory findings and imaging are not necessary for diagnosis
Pertussis[10][11] Acute
  • Two weeks
+ Whooping sound + + +
  • Clear chest
  • Normal function
  • Culture
Common Cold[12] Acute
  • 3−10 days
+ +
  • Bacterial culture is not indicated
  • Normal function
  • Clinical diagnosis
Tonsilitis[13][14][15] Acute or Acute Recurrent, Chronic
  • Varies
+(Mucus from inflamed tissue) −/+ + Odynophagia, Tachypnea
  • Rapid Antigen Detecting Test
  • Throat Swab Culture
  • EBV Heterophile Antibody Test
  • Monospot Test
  • Complete Blood Count
  • Chest X−Ray shows normal finding. USG may show Peritonsillar abscess.
  • Normal function
  • Rapid Antigen Detecting Test
Seasonal Influenza[16][17] Acute
  • Upper respiratory tract symptoms with fever peaking at three to four days, resolved by seven to ten days.
+(High grade) +
  • Normal function
  • Clinical diagnosis
Sinusitis[18][19] Acute, Subacute, Chronic, recurrent
  • Acute: < four weeks
  • Subacute: four−twelve weeks
  • Chronic: > twelve weeks
  • Recurrent: > four episodes / acute episode of rhinosinusitis yearly.
+ + +
  • Restlessness, Nasal Congestion, Post Nasal Drip, Facial Pain, Rhinorrhea
  • Air−fluid level, mucosal edema and bony erosion of sinus on CT
  • MRI for distinguish the etiology
  • Normal function

_

Organ system Diseases Clinical manifestations Diagnosis Other features
Symptoms Physical exam
Onset Duration Productive cough Hemoptysis Weight loss Fever Dyspnea Physical findings Lab findings Imaging PFT Gold standard
Respiratory Lower airway Asthma[20][21] Chronic
  • Years
+ Clear mucoid or yellow sputum +
  • Family history
  • Seasonal variation
Bacterial Protracted Bronchitis[22][23] Chronic
  • At least four weeks
+(Purulent) + +/− +
  • FEV1 < 80%
  • Clinical diagnosis
  • Majority of cases are caused by Streptococci Pneumoniae, Hemophylous Influenza, Staphylococcus aureus
Bronchiectasis[24][25][26] Chronic
  • Months to years
+ Mucopurulent sputum + +
  • CT of chest
'Foreign body aspiration[27][28][29] Acute
  • Sudden Onset
+ +/- +/- +
  • No specific tests
  • Not specific
  • In children <1 year
  • Organic materials in children
Bronchiolitis[30][31] Acute
  • 8−15 days
+ + +
  • Rhinorrhoea
  • Cyanosis, Hypoxia
  • Intercostal and subcostal retraction
  • Tachypnea
  • Wheezing
  • Crackles
  • Grunting and Nasal Flaring
  • Clinical diagnosis
Organ system Diseases Clinical manifestations Diagnosis Other features
Symptoms Physical exam
Onset Duration Productive cough Hemoptysis Weight loss Fever Dyspnea Physical Examination Lab findings Imaging PFT Gold standard
Respiratory Lung Parenchyma Pneumonia[32][33][34] Acute + + +
  • Crackles
  • Egophony
  • Decreased bronchial sounds, Rhonchi
  • Rapid Breathing
  • Intercostal retractions
  • Nasal Flaring, Grunting
  • Tachypnea, Tachycardia
  • Vomiting
  • Not specific
Tuberculosis (TB)[35] Chronic[36]
  • Weeks to months
+ + + + +
Organ system Diseases Clinical manifestations Diagnosis Other features
Symptoms Physical exam
Onset Duration Productive cough Hemoptysis Weight loss Fever Dyspnea Physical Examination Lab findings Imaging PFT Gold standard
Cardiac Cardiac Failure[37][38] Acute
  • Hours
+ + The following investigations may be helpful:
  • Not specific
  • Clinical diagnosis
  • Tests are supportive
Congenital Heart Disease Acute or Chronic
  • Variable
+ + +
  • Not specific
Organ system Diseases Clinical manifestations Diagnosis Other features
Symptoms Physical exam
Onset Duration Productive cough Hemoptysis Weight loss Fever Dyspnea Physical Examination Lab findings Imaging PFT Gold standard
Gastrointestinal Gastroesophageal reflux[39][40] Chronic
  • Variable
+ + +
*Apnea
  • Epigastric pain
  • Not specific
  • Normal function
  • PH testing
−−

Epidemiology and Demographics

Age

Gender

  • Boys are more commonly affected with cough than girls.[42]

Race

Risk Factors

Natural History, Complications and Prognosis

  • Prognosis is generally excellent and efficiently treatable in most of the etiology of cough in children.

Diagnosis

Diagnostic Criteria

  • Diagnosis of causes of a cough is made after a detailed history, presenting complaints and physical examination and laboratory findings in some cases. Cough can be classified according to:[48]
    • Duration.
    • Nature or quality of cough.
    • Etiology.
    • Anatomic location.
    • Grade.

A detailed history focusing on onset of disease, factors worsening the episodes, time of worsening, alleviating factors, amount of work to breathe, presence of shortness of breathing, relation with vomiting, food intake, posture, presence of blood, systemic findings (fever, weight loss, hypotension, syncope, vertigo, dizziness, failure to thrive), episodes of choking, household socioeconomic status, family history, vaccination history, drug abuse and smoking in family members, atopy, antenatal, perinatal, postnatal, birth history, developmental history, feeding history.

The following signs are alarming which need further emergent evaluation by the physician:

Symptoms

  • Cough may be associated with the following depending upon the cause:

Physical Examination

Laboratory Findings

Electrocardiogram

An ECG may not be helpful in the diagnosis of congenital heart disease, myocarditis, valvular heart disease, in children.

X-ray

Anterior/posterior view, lateral Chest and neck x-ray may be helpful in the diagnosis of causes of cough in children for: Pneumonia, Croup, Bronchitis, Epiglottitis, Foreign body impaction etc. X-ray of paranasal sinuses helps in diagnosis of sinusitis, deviated nasal septum.

Echocardiography or Ultrasound

Echocardiography/ultrasound may be helpful in the diagnosis of causes of cough in children. Echocardiographic findings aide in the diagnosis of congenital heart disease, whereas USG findings can help in evaluating complications like peritonsillar abscess, retropharyngeal abscess promptly.

CT scan

The High resolution CT is used for diagnosing causes of chronic cough in children such as bronchiectasis. Sometimes it helps in identifying congenital heart and lung anomalies.

MRI

A Chest MRI may be helpful in the diagnosis of the dynamic function of airways disease.[49]. MRI can provide detailed findings of perfusion, ventilation mechanism of lungs and diaphragm. It can show oxygen enhancement, congenital anomalies too.

Other Imaging Findings

Other imaging techniques are used to evaluate causes of cough in children.

Other Diagnostic Studies

Other investigations done to rule out differential diagnosis of cough in children are:

Treatment

Medical Therapy

Surgery

Prevention

  • Effective measures for the primary prevention of cough include:
    • Caregivers should be given health education on pros and cons of vaccination, alarming features of cough.
    • Physical hygiene including airways of an infant or a child should be maintained to prevent complications.
    • Head should be raised to prevent irritations in throat.
    • Humidified air will help clearing the sputum easily.
    • Adequate hydration to prevent formation of dry sputum.
    • Avoidance of triggers in case of atopic patient.
    • Nutritional balance should be maintained for rebooting the immunity.

References

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