Cough resident survival guide (pediatrics)
Synonyms and Keywords: Cough in childhood, Cough in children, An approach to cough in children
|Cough resident survival guide (pediatrics) Microchapters|
Cough is a sudden, often repetitive, spasmodic contraction of the thoracic cavity, resulting in a violent release of air from the lungs, and usually accompanied by a distinctive sound. A cough by itself is not a complete diagnosis but rather a symptom of an underlying condition, despite this, it accounts as one of the most common indications for visits to the general practitioners and family physicians with a good proportion of these cases resulting in a pulmonology referral. Coughing is an action the body takes to get rid of substances that are irritating the air passages. The act of coughing can be triggered by a myriad of conditions physiologic and otherwise. A cough is mostly initiated to clear a buildup of phlegm within the trachea. Coughing can also be triggered by a bolus of food entering the trachea and other parts of the respiratory tree rather than the esophagus due to a failure of the epiglottis function.
Life Threatening Causes
Life-threatening causes include conditions that may result in death or permanent disability within 24 hours if left untreated:
|Acute cough (less than 3 weeks)||Subacute (3 to 8 weeks) or chronic cough (3 to 4 months)|
Isolated cough: otherwise healthy child
Characterize the symptoms
❑ Chronic wet/productive cough
❑ Chest pain
❑ History suggestive of inhaled foreign body
❑ Exertional dyspnea
❑ Failure to thrive
❑ Cardiac anomaly
❑ Neurodevelopmental abnormalities
❑ Recurrent sinopulmonary infections
❑ Epidemiologic risk factors for exposure to TB
Consider the diagnosis of Bacterial bronchitis
Antibiotics for 2 to 4 weeks
Trial of Asthma therapies for 2 to 4 weeks
Perform tests to confirm the diagnosis and treat as appropriate
Shown below is an algorithm summarizing the treatment of underlying conditions that cause cough.
Treat the underlying causes
Cough due to Bronchiolitis
❑ Supportive care such as hydration, saline nasal drops, nasal bulb suction
❑ Prevention includes Palivizumab for infants with the following conditions:
Cough due to Common Cold
❑ Supportivr care such as hydration, saline nasal drops
❑ Combination of over the counter medications such as antihistamines, decongestants, antitussives, expectorants, mucolytics, antipyretics/analgesics
❑ For fever, acetaminophen (for children older than three months) or ibuprofen (for children older than six months)
Cough due to Asthma
❑ Humidified oxygen by nasal cannula or facemask
❑ Inhaled short-acting beta-2 agonists (SABAs) such as (albuterol/salbutamol)
❑ Systemic glucocorticoids (Oral prednisone or dexamethasone)
❑ ICU admission for severe exacerbation
❑ Antibiotics for bacterial pneumonia or sinusitis❑
Cough due to Pertussis
❑ Macrolides erythromycin, clarithromycin, and azithromycin are preferred for the treatment of pertussis in persons 1 month of age and older
❑ Azithromycin remains the drug of choice for treatment or prophylaxis of pertussis in infants younger than 1 month of age,
❑ Monitor the infant for the development of infantile hypertrophic pyloric stenosis (IHPS) with the use of oral erythromycin and azithromycin
❑ An alternative to macrolides is trimethoprim-sulfamethoxazole in infants 2 months of age and older
Cough due to Pneumonia
❑ Supportive care
❑ IV fluid therapy
❑ IV empiric antibiotic treatment
❑ For Severe pneumonia
❑ ICU admission
❑ Complicated pneumonia
Cough due to Influenza
❑ Oral oseltamivir for:
Treat the underlying causes
Cough due to Cystic fibrosis
❑ CFTR modulator such as tezacaftor-ivacaftor or lumacaftor-ivacaftor
❑ Metered-dose Albuterol Inhaler
❑ Hypertonic saline
❑ DNase such as dornase alfa
❑ Chest physiotherapy
❑ Aerosolized antibiotics or long-acting antiasthmatics
Cough due to Chronic bronchitis
protracted bacterial bronchitis
❑ Augmentin (amoxicillin and clavulanate potassium) or Omnicef (cefdinir)❑
Cough due to Primary ciliary dyskinesia 9387968
❑ Treatment should be individualized based on the clinical course of each patient
❑ Supplemental oxygen for a few hours to days after birth for mild respiratory distress (tachypnea, mild hypoxemia)
❑ Daily chest physiotherapy
❑ Oral antibiotics for acute exacerbation and it should be tailored based on the sputum culture results
❑ Preventive antibiotic therapy with Azithromycin may reduce the rate of exacerbations
Cough due to Postnasal drib (Allergic Rhinitis)
❑ Nasal steroid sprays reduce swelling and inflammation of the nasal passages promoting proper drainage
❑ Allergy shots (immunotherapy) if no improvement❑
Cough due to Cough variant asthma
❑ Inhaler with albuterol, ipratropium, and/or inhaled steroids❑
Cough due to Recurrent viral bronchitis
❑ Antibiotics are not recommended except with chronic wet cough for ≥ 2-4 weeks, which could be mostly bacterial ❑ Albuterol or terbutaline inhalers ❑ corticosteroids if no improvement ❑ Stepped-up courses of inhaled corticosteroids might be effective ❑❑
- "For children aged less than 14-years with chronic cough (> 4 weeks duration) without an underlying lung disease but who have symptoms and signs or tests consistent with gastroesophageal pathological reflux, they should be treated for GERD in accordance to evidence-based GERD specific guidelines (Grade 1B)." 
- "Children with chronic cough and typical symptoms of GERD should undergo medical treatment—dietary, lifestyle modifications and acid suppression therapy. A three-stage therapeutic trial should be completed before diagnosing reflux-related cough:
- (1) clear-cut response to a 4 to 8-week treatment with PPI
- (2) relapse on stopping medication
- (3) new response to recommencing medication, with weaning down therapy as appropriate to the child’s symptoms." 
- According to Chang et al., "for children aged less than 14-years with chronic cough (> 4 weeks duration) without an underlying lung disease, treatment for gastroesophageal reflux disease (GERD) should not be used when there are no clinical features of gastroesophageal reflux such as recurrent regurgitation, dystonic neck posturing in infants, or heartburn/epigastric pain in older children (Grade1B)." 
- For children aged less than 14-years with chronic cough (> 4 weeks duration) without an underlying lung disease but who have symptoms and signs or tests consistent with gastroesophageal pathological reflux, acid suppressive therapy should not be used solely for their chronic cough (Grade 1C). 
- According to CHEST guidelines 2017, "For children aged less than 14-years with chronic cough, basing the management on the etiology of the cough is recommended. An empirical approach aimed at treating upper airway cough syndrome due to a rhinosinus condition, GERD and/or asthma should not be used unless other features consistent with these conditions are present." 
- “In otherwise well children with nonspecific cough, empirical gastroesophageal reflux therapy is unlikely to be beneficial and is generally not recommended.” 
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