Cough resident survival guide (pediatrics)
Editor-In-Chief: C. Michael Gibson, M.S., M.D.  Associate Editor(s)-in-Chief: Maysoon Fatahi, MD,Tayyaba Ali, M.D., 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:
|Acute cough (less than 3 weeks)||Subacute (3 to 8 weeks) or chronic cough (3 to 4 months)|
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.
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
Examine the patient
❑ Respiratory distress
❑ Digital clubbing
❑ Chest wall deformity
❑ Auscultatory crackles
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 rigid bronchoscopy for foreign body removal
Perform tests to confirm the diagnosis and treat as appropriate
❑ 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:
No foreign body
❑ Reassess for other causes of cough
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.” 
- ↑ 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.
- ↑ 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.
- ↑ "Acute Asthma: Observations Regarding the Management of a Pediatric Emergency Room | American Academy of Pediatrics".
- ↑ 4.0 4.1 "www.ncbi.nlm.nih.gov" (PDF).
- ↑ 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.
- ↑ 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.
- ↑ 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.
- ↑ 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.
- ↑ "Treatment of the Common Cold - American Family Physician".
- ↑ 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.
- ↑ 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.
- ↑ 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.
- ↑ 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.
- ↑ 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.
- ↑ 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.
- ↑ 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.
- ↑ 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.
- ↑ 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.
- ↑ 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.
- ↑ 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.
- ↑ 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.
- ↑ 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.
- ↑ 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.
- ↑ 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.
- ↑ 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.
- ↑ 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.
- ↑ 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.
- ↑ 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.
- ↑ 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.
- ↑ 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.
- ↑ 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.
- ↑ "Overview | Gastro-oesophageal reflux disease in children and young people: diagnosis and management | Guidance | NICE".
- ↑ 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.
- ↑ 35.0 35.1 "journal.chestnet.org".
- ↑ 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.