Cough resident survival guide (pediatrics)

Jump to navigation Jump to search


Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Maysoon Fatahi, MD[2],Tayyaba Ali, M.D.[3], Huda A. Karman, M.D.

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:

Common Causes

Acute cough (less than 3 weeks)[4] Subacute (3 to 8 weeks) or chronic cough (3 to 4 months)[5]

Isolated cough: otherwise healthy child


The approach to diagnosis of Cough in children is based on a step-wise testing strategy. Below is an algorithm summarising the identification and laboratory diagnosis of Cough.[6][7]

Order Chest X-ray or spirometry (if child is able to perform)
Consider the diagnosis of Bacterial bronchitis
Consider the diagnosis of Asthma
❑ History of bilateral wheeze and exertional dyspnea
❑ Absence of other cough symptoms
❑ Absence of findings on lung examination
Reversible obstructive defect or normal finding on spirometry (if performed)
Consider the diagnosis of Retained foreign body
❑ History of choking or sudden onset of symptoms
❑ Monophonic or unilateral wheeze
❑ Chest X-ray finding suggesting foreign body
Consider the other type of cough
Habit cough/ tic cough (typically absent at night or when distracted and may be honking or short/dry)
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
Cough resolves
❑ Likely bacterial bronchitis
❑ Reassess in 3 to 4 months to confirm that child remains well
Productive cough continues after 4 weeks
❑ Consider the diagnosis of:
Asthma Improved
❑ Continue treatment
Asthma not improved
❑ Reassess for other causes of cough
No foreign body
❑ Reassess for other causes of cough


Shown below is an algorithm summarizing the treatment of underlying conditions that cause cough.

Acute cough

Treat the underlying causes
Cough due to Bronchiolitis[8]
❑ 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[9]
❑ 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[10][11]

❑ 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

  • Systemic beta-agonists, methylxanthines, and magnesium sulfate
  • noninvasive positive pressure ventilation and high-flow nasal cannula

❑ Antibiotics for bacterial pneumonia or sinusitis

Cough due to Pertussis[12][13]

❑ 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 Croup[14][15][16]

❑ Comfort measures (keep the child calm as crying worsen airway obstruction

❑ A single dose of dexamethasone if symptoms persist for>3-5 days or worsen

❑ An inhaled epinephrine using a nebulizer for more severe symptoms
Cough due to Pneumonia[17][18][19]

Inpatient treatment

❑ Supportive care

  • Antipyretics and/or analgesics (acetaminophen, ibuprofen)

❑ Supplemental oxygen to maintain oxygen saturation ≥95 percent

❑ IV fluid therapy

❑ IV empiric antibiotic treatment

  • 1-6 months old (Ceftriaxone or Cefotaxime)
  • ≥6 months (Ampicillin or penicillin G is preferred)
  • For C. trachomatis, M. pneumoniae or C. pneumoniae (Azithromycin)

❑ For Severe pneumonia

  • Ceftriaxone or Cefotaxime plus Macrolide (Azithromycin)

❑ ICU admission

  • Vancomycin plus Ceftriaxone or Cefotaxime plus Azithromycin plus Antiviral if hospitalized during influenza season)

❑ Complicated pneumonia

  • Ceftriaxone or Cefotaxime plus Clindamycin if S. aureus or anaerobic is suspected
Cough due to Influenza[20]

❑ Oral oseltamivir for:

  • Hospitalized patients
  • Patients with severe, complicated, or progressive illness
  • Patients with risk factors for complications

Chronic cough

Treat the underlying causes
Cough due to Cystic fibrosis[21][22][23][24]

❑ CFTR modulator such as tezacaftor-ivacaftor or lumacaftor-ivacaftor

  • CFTR genotyping should be done first to determine the patient eligibility
    • Patients ≥12 years old with responsive CFTR mutations
    • Younger patients with sufficient evidence for FDA approval

❑ Metered-dose Albuterol Inhaler

❑ Hypertonic saline

❑ DNase such as dornase alfa

❑ Chest physiotherapy

❑ Exercise

❑ Aerosolized antibiotics or long-acting antiasthmatics

❑ Azithromycin

  • Chronic treatment with for patients six years and older
Cough due to Chronic bronchitis

protracted bacterial bronchitis

❑ Augmentin (amoxicillin and clavulanate potassium) or Omnicef (cefdinir)

Cough due to Primary ciliary dyskinesia[25][26][27] 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

  • Do Sputum cultures prior to Azithromycin use to exclude nontuberculous mycobacteria infection
  • Assess for risk of QT interval prolongation prior to Azithromycin use
Cough due to Postnasal drib (Allergic Rhinitis)[28]

❑ Antihistamines

❑ 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[29]

❑ 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 ❑

Cough due to Asthma[30][31]

Mild, persistent asthma ❑ low-dose, daily inhaled glucocorticoids ❑ Daily leukotriene receptor antagonist (Montelukast )

  • As an alternative to inhaled glucocorticoids
  • Limited use due to neuropsychiatric sede effects


  • "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)." [32][33]
  • "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." [34]



  1. Patocka C, Nemeth J (2012). "Pulmonary embolism in pediatrics". J Emerg Med. 42 (1): 105–16. doi:10.1016/j.jemermed.2011.03.006. PMID 21530139.
  2. Tan TQ, Mason EO, Wald ER, Barson WJ, Schutze GE, Bradley JS; et al. (2002). "Clinical characteristics of children with complicated pneumonia caused by Streptococcus pneumoniae". Pediatrics. 110 (1 Pt 1): 1–6. doi:10.1542/peds.110.1.1. PMID 12093940.
  3. "Acute Asthma: Observations Regarding the Management of a Pediatric Emergency Room | American Academy of Pediatrics".
  4. 4.0 4.1 "" (PDF).
  5. 5.0 5.1 de Jongste JC, Shields MD (2003). "Cough . 2: Chronic cough in children". Thorax. 58 (11): 998–1003. doi:10.1136/thorax.58.11.998. PMC 1746521. PMID 14586058.
  6. Rochwerg B, Brochard L, Elliott MW, Hess D, Hill NS, Nava S; et al. (2017). "Official ERS/ATS clinical practice guidelines: noninvasive ventilation for acute respiratory failure". Eur Respir J. 50 (2). doi:10.1183/13993003.02426-2016. PMID 28860265.
  7. Weinberger M, Hoegger M (2016). "The cough without a cause: Habit cough syndrome". J Allergy Clin Immunol. 137 (3): 930–1. doi:10.1016/j.jaci.2015.09.002. PMID 26483178.
  8. King VJ, Viswanathan M, Bordley WC, Jackman AM, Sutton SF, Lohr KN; et al. (2004). "Pharmacologic treatment of bronchiolitis in infants and children: a systematic review". Arch Pediatr Adolesc Med. 158 (2): 127–37. doi:10.1001/archpedi.158.2.127. PMID 14757604.
  9. "Treatment of the Common Cold - American Family Physician".
  10. Ben-Zvi Z, Lam C, Hoffman J, Teets-Grimm KC, Kattan M (1982). "An evaluation of the initial treatment of acute asthma". Pediatrics. 70 (3): 348–53. PMID 7110806.
  11. Rodrigo GJ, Rodriquez Verde M, Peregalli V, Rodrigo C (2003). "Effects of short-term 28% and 100% oxygen on PaCO2 and peak expiratory flow rate in acute asthma: a randomized trial". Chest. 124 (4): 1312–7. doi:10.1378/chest.124.4.1312. PMID 14555560.
  12. Tozzi AE, Celentano LP, Ciofi degli Atti ML, Salmaso S (2005). "Diagnosis and management of pertussis". CMAJ. 172 (4): 509–15. doi:10.1503/cmaj.1040766. PMC 548414. PMID 15710944.
  13. Tablan OC, Anderson LJ, Besser R, Bridges C, Hajjeh R, CDC; et al. (2004). "Guidelines for preventing health-care--associated pneumonia, 2003: recommendations of CDC and the Healthcare Infection Control Practices Advisory Committee". MMWR Recomm Rep. 53 (RR-3): 1–36. PMID 15048056.
  14. Gates A, Gates M, Vandermeer B, Johnson C, Hartling L, Johnson DW; et al. (2018). "Glucocorticoids for croup in children". Cochrane Database Syst Rev. 8: CD001955. doi:10.1002/14651858.CD001955.pub4. PMC 6513469 Check |pmc= value (help). PMID 30133690.
  15. Westley CR, Cotton EK, Brooks JG (1978). "Nebulized racemic epinephrine by IPPB for the treatment of croup: a double-blind study". Am J Dis Child. 132 (5): 484–7. doi:10.1001/archpedi.1978.02120300044008. PMID 347921.
  16. Klassen TP, Watters LK, Feldman ME, Sutcliffe T, Rowe PC (1996). "The efficacy of nebulized budesonide in dexamethasone-treated outpatients with croup". Pediatrics. 97 (4): 463–6. PMID 8632929.
  17. Bradley JS, Byington CL, Shah SS, Alverson B, Carter ER, Harrison C; et al. (2011). "The management of community-acquired pneumonia in infants and children older than 3 months of age: clinical practice guidelines by the Pediatric Infectious Diseases Society and the Infectious Diseases Society of America". Clin Infect Dis. 53 (7): e25–76. doi:10.1093/cid/cir531. PMC 7107838 Check |pmc= value (help). PMID 21880587.
  18. Harris M, Clark J, Coote N, Fletcher P, Harnden A, McKean M; et al. (2011). "British Thoracic Society guidelines for the management of community acquired pneumonia in children: update 2011". Thorax. 66 Suppl 2: ii1–23. doi:10.1136/thoraxjnl-2011-200598. PMID 21903691.
  19. Chang CC, Cheng AC, Chang AB (2014). "Over-the-counter (OTC) medications to reduce cough as an adjunct to antibiotics for acute pneumonia in children and adults". Cochrane Database Syst Rev (3): CD006088. doi:10.1002/14651858.CD006088.pub4. PMID 24615334.
  20. "Influenza Antiviral Medications: Summary for Clinicians | CDC".
  21. Heijerman HGM, McKone EF, Downey DG, Van Braeckel E, Rowe SM, Tullis E; et al. (2019). "Efficacy and safety of the elexacaftor plus tezacaftor plus ivacaftor combination regimen in people with cystic fibrosis homozygous for the F508del mutation: a double-blind, randomised, phase 3 trial". Lancet. 394 (10212): 1940–1948. doi:10.1016/S0140-6736(19)32597-8. PMID 31679946.
  22. Walker S, Flume P, McNamara J, Solomon M, Chilvers M, Chmiel J; et al. (2019). "A phase 3 study of tezacaftor in combination with ivacaftor in children aged 6 through 11 years with cystic fibrosis". J Cyst Fibros. 18 (5): 708–713. doi:10.1016/j.jcf.2019.06.009. PMID 31253540.
  23. Flume PA, O'Sullivan BP, Robinson KA, Goss CH, Mogayzel PJ, Willey-Courand DB; et al. (2007). "Cystic fibrosis pulmonary guidelines: chronic medications for maintenance of lung health". Am J Respir Crit Care Med. 176 (10): 957–69. doi:10.1164/rccm.200705-664OC. PMID 17761616.
  24. Mogayzel PJ, Naureckas ET, Robinson KA, Mueller G, Hadjiliadis D, Hoag JB; et al. (2013). "Cystic fibrosis pulmonary guidelines. Chronic medications for maintenance of lung health". Am J Respir Crit Care Med. 187 (7): 680–9. doi:10.1164/rccm.201207-1160oe. PMID 23540878.
  25. Knowles MR, Daniels LA, Davis SD, Zariwala MA, Leigh MW (2013). "Primary ciliary dyskinesia. Recent advances in diagnostics, genetics, and characterization of clinical disease". Am J Respir Crit Care Med. 188 (8): 913–22. doi:10.1164/rccm.201301-0059CI. PMC 3826280. PMID 23796196.
  26. Hosie PH, Fitzgerald DA, Jaffe A, Birman CS, Rutland J, Morgan LC (2015). "Presentation of primary ciliary dyskinesia in children: 30 years' experience". J Paediatr Child Health. 51 (7): 722–6. doi:10.1111/jpc.12791. PMID 25510893.
  27. Barbato A, Frischer T, Kuehni CE, Snijders D, Azevedo I, Baktai G; et al. (2009). "Primary ciliary dyskinesia: a consensus statement on diagnostic and treatment approaches in children". Eur Respir J. 34 (6): 1264–76. doi:10.1183/09031936.00176608. PMID 19948909.
  28. Pratter MR (2006). "Chronic upper airway cough syndrome secondary to rhinosinus diseases (previously referred to as postnasal drip syndrome): ACCP evidence-based clinical practice guidelines". Chest. 129 (1 Suppl): 63S–71S. doi:10.1378/chest.129.1_suppl.63S. PMID 16428694.
  29. Pender ES, Pollack CV (1990). "Cough-variant asthma in children and adults: case reports and review". J Emerg Med. 8 (6): 727–31. doi:10.1016/0736-4679(90)90287-6. PMID 2096171.
  30. Childhood Asthma Management Program Research Group. Szefler S, Weiss S, Tonascia J, Adkinson NF, Bender B; et al. (2000). "Long-term effects of budesonide or nedocromil in children with asthma". N Engl J Med. 343 (15): 1054–63. doi:10.1056/NEJM200010123431501. PMID 11027739.
  31. Jartti T (2008). "Inhaled corticosteroids or montelukast as the preferred primary long-term treatment for pediatric asthma?". Eur J Pediatr. 167 (7): 731–6. doi:10.1007/s00431-007-0644-3. PMID 18214538.
  32. Rosen R, Vandenplas Y, Singendonk M, Cabana M, DiLorenzo C, Gottrand F; et al. (2018). "Pediatric Gastroesophageal Reflux Clinical Practice Guidelines: Joint Recommendations of the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition and the European Society for Pediatric Gastroenterology, Hepatology, and Nutrition". J Pediatr Gastroenterol Nutr. 66 (3): 516–554. doi:10.1097/MPG.0000000000001889. PMC 5958910. PMID 29470322.
  33. "Overview | Gastro-oesophageal reflux disease in children and young people: diagnosis and management | Guidance | NICE".
  34. 34.0 34.1 de Benedictis FM, Bush A (2018). "Respiratory manifestations of gastro-oesophageal reflux in children". Arch Dis Child. 103 (3): 292–296. doi:10.1136/archdischild-2017-312890. PMID 28882881.
  35. 35.0 35.1 "".
  36. Chang AB, Oppenheimer JJ, Weinberger MM, Rubin BK, Grant CC, Weir K; et al. (2017). "Management of Children With Chronic Wet Cough and Protracted Bacterial Bronchitis: CHEST Guideline and Expert Panel Report". Chest. 151 (4): 884–890. doi:10.1016/j.chest.2017.01.025. PMID 28143696.