Download Approach to chronic cough in children Author: Roni Grad, MD

Approach to chronic cough in children
Author:
Roni Grad, MD
Section Editor:
George B Mallory, MD
Deputy Editor:
Alison G Hoppin, MD
Contributor Disclosures
All topics are updated as new evidence becomes available and our peer review process is
complete.
Literature review current through: Nov 2016. | This topic last updated: Jun 29, 2015.
INTRODUCTION — Coughing is an important defensive reflex that protects from aspiration of
foreign materials, and enhances clearance of secretions and particulates from the airways.
Healthy children may cough on a daily basis; one study documented an average of 11 cough
episodes every 24 hours [1]. However, a cough may also be the presenting symptom of a
serious underlying pulmonary or extrapulmonary disease. The causes of chronic cough in
children are quite different from that of adults, so evaluation and management of children should
not be based on adult protocols. Adolescents 15 years and older may be evaluated using
guidelines for adults [2]. (See "Evaluation of subacute and chronic cough in adults".)
The differential diagnosis of chronic cough in children includes subacute and chronic infections
(eg, bacterial bronchitis, pertussis, mycoplasma, and tuberculosis), foreign body aspiration, and
cough-dominant asthma (table 1) [3]. Gastroesophageal reflux, upper airway cough syndrome
(formerly known as postnasal drip syndrome), and sinusitis are sometimes implicated because
of associations with chronic cough in adults, but their role in causing chronic cough in children is
controversial [2]. Warning signs warranting concern include a cough that is unusually
severe and/or frequent, failure to thrive, growth retardation, purulent sputum, exertional
dyspnea, hypoxemia, chest pain, or hemoptysis. (See "Causes of chronic cough in children".)
An approach to the diagnosis and management of chronic cough in children is presented here.
Approaches to wheezing and stridor in children are presented separately. (See "Approach to
wheezing in infants and children"and "Wheezing illnesses other than asthma in
children" and "Assessment of stridor in children".)
EPIDEMIOLOGY — Epidemiologic studies of cough in children have been hampered by the
variable definitions used for defining chronicity, the presence of other concomitant symptoms
(eg, wheezing), the lack of widely accepted objective clinical endpoints to measure cough
severity, and the tendency for cough to resolve spontaneously [4,5].
Despite these limitations, chronic cough appears to be common, with an estimated prevalence
of 5 to 7 percent in preschoolers, and 12 to 15 percent in older children [6,7]. Cough is more
common among boys than girls up to 11 years of age [6], and may be less common in
developing countries than in affluent countries [8].
DEFINITION — There is no consensus as to the length of time in the definition of chronic cough
in children. The American College of Chest Physicians (ACCP), Thoracic Society of Australia
and New Zealand (TSANZ), and many studies have defined chronic cough as one that lasts
more than four weeks, because most acute respiratory infections in children resolve within this
interval [2,9]. In comparison, guidelines from the British Thoracic Society (BTS) define chronic
cough as one that lasts more than eight weeks [10]. However, these guidelines also describe a
"prolonged acute cough" as one that lasts at least three weeks and is "relentlessly progressive";
this type of cough may warrant investigation before eight weeks.
PHYSIOLOGY
Pathways — Each cough occurs through the stimulation of a complex reflex arc (figure 1)
[3,11]. This is initiated by the irritation of cough receptors that exist not only in the epithelium of
the upper and lower respiratory tracts, but also in the pericardium, esophagus, diaphragm,
stomach, and external ear [12,13].
Chemical receptors sensitive to acid, heat, and capsaicin-like compounds trigger the cough
reflex via activation of the type 1 vanilloid (capsaicin) receptor [14]. In addition, mechanical
cough receptors can be triggered by touch or displacement. The proximal airways (larynx and
trachea) are more sensitive to mechanical stimulation, and the distal airways more sensitive to
chemical stimulation. Irritation at the bronchiolar and alveolar level does not cause cough.
Impulses from stimulated cough receptors traverse afferent branches of the vagus nerve to a
"cough center" in the medulla and nucleus tractus solitarius, which itself is under control by
higher cortical centers. The cough center generates an efferent signal that travels down the
vagus, phrenic, and spinal motor nerves to expiratory musculature to produce the cough (figure
1) [3,11]. The pelvic sphincter muscles are also stimulated to contract, avoiding urinary
incontinence.
The mechanical events of a cough can be divided into three phases [15]:
●Inspiratory phase – Inhalation, which generates the volume necessary for an effective
cough.
●Compression phase – Closure of the larynx combined with contraction of muscles of
chest wall, diaphragm, and abdominal wall result in a rapid rise in intrathoracic pressure.
●Expiratory phase – The glottis opens, resulting in high expiratory airflow and the coughing
sound. Large airway compression occurs. The high flows dislodge mucus from the airways
and allow removal from the tracheobronchial tree.
The specific pattern of the cough depends on the site and type of stimulation. Mechanical
laryngeal stimulation results in immediate expiratory stimulation (sometimes termed the
expiratory reflex), probably to protect the airway from aspiration; stimulation distal to the larynx
causes a more prominent inspiratory phase, presumably to generate the airflow necessary to
remove the stimulus.
Ineffective cough — Cough is an important defensive reflex that is required to maintain the
health of the lungs. Children who do not cough effectively are at risk for atelectasis, recurrent
pneumonia, and chronic airways disease from aspiration and retention of secretions. Many
disorders can impair a child's ability to cough effectively, resulting in persistent cough. Children
with neuromuscular disease and chest wall deformities may not generate a deep enough
inspiratory volume or expiratory flow necessary for effective clearance of secretions due to
defective "pump" mechanisms [16]. Children with reduced function of the abdominal wall
musculature are particularly at risk for ineffective cough. Children with tracheo-bronchomalacia
("floppy" airways), or with obstructive airways diseases, often do not generate the high flow
rates needed for effective clearance of secretions. Individuals with laryngeal disorders, including
those with tracheostomies, may not achieve sufficient laryngeal closure to generate the
increased intrathoracic pressures necessary for an effective cough [11,12].
DIAGNOSTIC APPROACH — The diagnostic approach outlined in this topic review assumes a
definition of chronic cough that has lasted at least four weeks. Some presenting symptoms
warrant earlier evaluation (eg, onset after an episode of choking, suggesting foreign body
aspiration). One study suggests evaluation and treatment of children by experienced respiratory
specialists using a standardized protocol typically led to resolution of the cough within six
weeks, suggesting that earlier implementation of a standardized protocol is valuable [17]. The
protocol used in this study was similar to that outlined below.
Children with chronic cough should be evaluated with a detailed history, physical examination,
chest radiograph, and (if the child is able) spirometry [2,3,5,7]. This evaluation often provides
sufficient information to categorize the cough as specific (ie, caused by an underlying disease)
or nonspecific (no evidence of an underlying disease).
Further evaluation depends on the provisional diagnosis and the course of the symptoms
(algorithm 1).
Specific cough — The causes of specific chronic cough fall into the following general
categories (table 2):
●Asthma
●Protracted bacterial bronchitis
●Chronic suppurative lung disease and bronchiectasis
●Airway abnormality (congenital, foreign body, or neoplastic)
●Aspiration
●Chronic or less common infections
●Interstitial lung disease
●Extrapulmonary causes: cardiac abnormalities, ear conditions
The sequence of evaluation for these disorders is informed by the age and presenting features
of the child. Identification of the presenting features and cough characteristics is important
because many are easily recognizable and strongly suggestive of a specific cause; this is less
true in adults. (See "Causes of chronic cough in children".)
Key symptoms and signs — Certain symptoms and signs are highly predictive of a specific
cough. These signs or symptoms narrow the diagnostic possibilities and call for further specific
testing or referral (algorithm 1) [1,2]:
●Chronic wet cough
●Wheezing or crepitations
●Onset after an episode of choking, or sudden onset while eating or playing
●Abnormal chest radiography or spirometry
●Associated cardiac or neurologic abnormalities
●Failure to thrive, feeding difficulties, or hemoptysis
In particular, the symptom of a chronic wet cough, with or without production of purulent sputum,
is always pathologic and warrants investigations for a persistent endobronchial infection
(protracted bacterial bronchitis or chronic suppurative lung disease), retained airway foreign
body, or immunodeficiency [1] (see "Causes of chronic cough in children", section on 'Specific
cough'). Protracted bacterial bronchitis (PBB) is usually diagnosed based on the presence of an
isolated chronic wet-moist cough in a child who otherwise appears well, with resolution of the
cough after antibiotic treatment, and absence of symptoms, signs, or laboratory evidence
suggestive of an alternative cause of the cough. Children with suspected PBB should be treated
with antibiotics, usually selected empirically. Treatment with amoxicillin-clavulanate has been
effective in a clinical trial. (See"Causes of chronic cough in children", section on 'Protracted
bacterial bronchitis'.)
Nonspecific cough — If symptoms suggesting specific cough are absent and the chest
radiograph and spirometry are normal, a presumptive diagnosis of nonspecific cough should be
made (algorithm 1). If the cough is troublesome, the possibility of asthma should be considered
and pursued with an empiric trial of bronchodilators and other asthma medications.
(See "Causes of chronic cough in children", section on 'Asthma'.)
If there is no response, the child should be considered to have a nonspecific cough, and the
medication should be stopped. The child and parents should be reassured and the patient
observed over time for possible emergence of specific symptoms.
HISTORY — The diagnostic approach outlined above requires a detailed history, which should
focus on the following key elements:
Age and circumstances at onset — Neonatal onset of coughing should prompt consideration
of congenital malformations (eg, tracheobronchomalacia), conditions predisposing to aspiration
(eg, tracheoesophageal fistula, laryngeal cleft, or a neurological disorder), or chronic pulmonary
infections (eg, cystic fibrosis or ciliary dyskinesia). (See "Congenital anomalies of the
intrathoracic airways and tracheoesophageal fistula" and "Cystic fibrosis: Clinical manifestations
and diagnosis".)
A cough that begins suddenly while playing or eating, especially in the toddler age range,
should raise suspicion of an aspirated foreign body in the airway. The physician should
specifically ask about a history of choking, because this may have occurred weeks before and
the family may not voluntarily recall the information. Even if there is no history of choking, a
foreign body remains a diagnostic possibility. (See "Airway foreign bodies in children".)
An episode of severe pneumonia can damage the airways, making the child vulnerable to
chronic cough. More rarely, severe pneumonia may cause frank bronchiectasis. A psychogenic
or habitual cough also often begins after an upper respiratory infection.
Nature of the cough — Chronic paroxysmal cough triggered by exercise, cold air, sleep, or
allergens is often seen in patients with asthma. Barking or brassy cough suggests a process in
the trachea or more proximal airways, such as airway malacia or vascular compression,
laryngotracheobronchitis, spasmodic croup, or foreign body. Staccato cough in young infants
can be the result of infection with Chlamydia trachomatis. Cough that is honking ("Canadian
Goose-like") and disappears at night suggests a psychogenic or habitual cough.
A chronic productive (or "wet-moist") cough suggests a suppurative process, and may require
further investigation to exclude bronchiectasis, cystic fibrosis, active infection, immune
deficiency, or congenital malformation. In a study of children presenting with chronic cough, a
wet-moist quality to the cough was the most useful clinical marker of predicting a specific
etiology (sensitivity of 96 percent, although specificity was only 26 percent) [18]. Specific causes
of chronic wet-moist cough include bacterial bronchitis (40 percent of young children with wet
cough in one series), bronchiectasis, asthma-like conditions, and aspiration disorders [19].
(See 'Specific cough' above.)
Acute or subacute paroxysmal cough suggests infection with pertussis or parapertussis; this
characteristic cough can be retriggered by subsequent upper respiratory illness. An inspiratory
"whoop", when present, is an important diagnostic clue. The diagnosis can be difficult to
ascertain, as cultures are typically negative after the fourth week of illness, and convalescentphase serology can be difficult to interpret unless acute-phase titers were also obtained.
(See "Pertussis infection in infants and children: Clinical features and diagnosis", section on
'Clinical features'.)
Timing and triggers — The timing and triggers associated with cough can help guide
diagnosis. Cough due to asthma typically occurs following exposure to characteristic asthma
triggers (ie, allergens, smoke, exercise, cold air, or viral infection), and typically worsens during
sleep. Cough associated with nasal problems typically is worst during changes of position, while
cough due to bronchiectasis typically is worst and most productive early in the day.
Cough that is triggered during swallowing is suggestive of aspiration, either primary or due to
tracheoesophageal fistula or laryngeal abnormalities. Cough in the first hour after meals, or
which is worse while supine, may reflect gastroesophageal reflux. Psychogenic cough is present
during the day, disappears at night, and is typically worst and most disruptive during school
classes. (See "Congenital anomalies of the larynx" and "Clinical manifestations and diagnosis of
gastroesophageal reflux disease in children and adolescents".)
Associated symptoms — A history of dyspnea or hemoptysis should trigger a search for an
underlying lung disease. Hemoptysis should also raise concerns of bronchiectasis, cavitary lung
disease (tuberculosis or bacterial abscesses), heart failure, hemosiderosis, neoplasm, foreign
bodies, vascular lesions, endobronchial lesions, catamenial bleeding, and clotting disorders
[20]. (See "Hemoptysis in children".)
Cough, with or without symptoms of pancreatic insufficiency, recurrent endobronchial
infection, and/or failure to thrive should raise suspicion of cystic fibrosis. Cough associated with
persistent fever, and/or failure to thrive, or weight loss should raise suspicion of chronic infection
and immune deficiency. Children with neurologic impairment or seizures frequently have chronic
aspiration. Rarely, children with an abnormality of the central nervous system such as Chiari
type 1 malformation present with chronic cough due to swallowing dysfunction, usually in
association with headache [21]. (See "Cystic fibrosis: Clinical manifestations and
diagnosis" and"Approach to the child with recurrent infections".)
Anaphylactic reactions to food can include cough but are unlikely to present with recurrent
cough in the absence of other symptoms of anaphylaxis. (See "Food-induced anaphylaxis",
section on 'Signs and symptoms'.)
Past medical history — The past medical history should include an account of the pregnancy,
labor, and delivery, as well as the neonatal course. Low birth weight and/or premature neonates
are at risk for developing atopic sensitization and asthma. In addition, prematurity and neonatal
respiratory distress syndrome are precursors for bronchopulmonary dysplasia, which may cause
persistent respiratory symptoms in children and adolescents. (See "Risk factors for asthma",
section on 'Pre- and perinatal factors' and "Pathogenesis and clinical features of
bronchopulmonary dysplasia".)
The past medical history should also include questions related to eczema and pulmonary
infections. In preschool children, a history of infantile eczema is often associated with inhalant
allergy [22]. Coughing episodes diagnosed as pneumonia may or may not have been related to
other pulmonary processes, as discussed below.
Recurrent right middle lobe atelectasis or infiltrates are common in children with asthma and
other processes that cause increased mucus production, due to relatively poor collateral
ventilation in the right middle lobe. This is frequently mistaken for pneumonia. A history of
recurrent or unresolving pneumonia in one lobe or segment of the lung may also be caused by
obstruction or anatomic abnormality in that airway. (See "Congenital anomalies of the
intrathoracic airways and tracheoesophageal fistula".)
In children with chronic cough and a history of recurrent pneumonias involving multiple lobes,
considerations include cystic fibrosis, immune deficiency, aspiration (swallowing dysfunction,
gastroesophageal reflux, tracheoesophageal fistula), primary ciliary dyskinesia and autoimmune
disease. Severe infection caused by pertussis or adenovirus has been associated with the
subsequent development of bronchiectasis, bronchiolitis obliterans, and chronic lung disease. If
the child is known to be immunodeficient, atypical and/or chronic infections of the
sinuses and/or lungs should be suspected. (See "Approach to the child with recurrent
infections".)
Family history — Family history of atopy or asthma increases the risk in offspring, and
suggests a diagnosis of either allergic rhinitis or asthma in the child with chronic cough [22,23].
Family history of cystic fibrosis or primary ciliary dyskinesia should raise suspicion for these
disorders. A careful history should be obtained for current illness in family members or close
contacts; such individuals with cough, weight loss, and night sweats should arouse suspicion of
tuberculosis. In some cases, the possibility of HIV transmission from mother to child should be
assessed.
Social history and environmental exposures — Passive or active exposure to smoke from
tobacco [22], marijuana, cocaine or other chemical irritants can result in chronic cough. Indoors,
damp homes are associated with chronic respiratory complaints [24]. In addition, wood-burning
stoves cause indoor air pollution and can predispose children to respiratory infections [25]. Gas
stoves are also associated with respiratory symptoms in children [26]. These environmental
exposures are important exacerbating factors for chronic cough in some children but are not
necessarily the sole causative factors [27]. (See "Secondhand smoke exposure: Effects in
children" and "Cocaine: Acute intoxication".)
Residence in the inner cities of the United States is associated with exposure to cockroaches
and mice, which are common allergens in these environments [28,29]. Outdoor air pollution in
inner cities is also associated with chronic cough [30-32]. Indoor air pollution due to the use of
biomass fuels (wood and crop residues and animal dung) is common in developing countries;
this may predispose children to respiratory infections [33].
It is important to elicit any history of contact with pets or other animals, as cough may be
induced by allergy to the animals. Similarly, the location of the child's home and travel history
may be relevant. Local epidemiology can inform the diagnostic considerations, especially with
respect to endemic fungal and parasitic infections (table 3). Histoplasmosis is commonly
associated with exposure to birds and bats, and echinococcosis with exposure to dogs and
sheep. Residents of the Southwestern United States, Northern Mexico, and parts of Central and
South America are at risk for coccidiomycosis. (See "Pathogenesis and clinical manifestations
of disseminated histoplasmosis" and "Clinical manifestations and diagnosis of
echinococcosis" and "Primary coccidioidal infection".)
The symptom of chronic cough is a source of stress and concern for patients and their families.
Acknowledging this and other sources of stress may facilitate communication and appropriate
counseling [34]. A questionnaire has been developed and validated for assessing the effect of
the child's cough on the parent's quality of life [35].
Medications — Response to prior therapy may yield some diagnostic clues regarding the
cause of chronic cough. Previous response to antihistamines suggests a component of rhinitis
and postnasal drip, while a response to inhaled bronchodilators suggests possible asthma.
However, any prior response to medication needs to be interpreted with great caution, since
symptoms can spontaneously remit. Previous response to antibiotics and asthma therapies
should be interpreted with special caution, as antibiotics are frequently prescribed for self-limited
viral illnesses, and the cough may have resolved spontaneously regardless of treatment.
Any medications taken by the patient should be reviewed carefully; angiotensin converting
enzyme (ACE) inhibitors are a well-established cause of chronic cough. Patients previously
treated with cytotoxic drugs or thoracic radiation are at risk of interstitial lung disease.
(See "Approach to the infant and child with diffuse lung disease (interstitial lung disease)".)
PHYSICAL EXAMINATION
General examination — The physical examination should pay close attention to the following
signs of chronic underlying disease:
●General appearance of chronic illness
●Poor growth, thinness, or obesity
●Increased work of breathing, retractions, accessory muscle use, chest wall hyperinflation
or deformity, abnormal breath sounds (reduced intensity, asymmetry, wheezing, stridor,
crackles)
●Shiners, swollen nasal turbinates, nasal obstruction, nasal polyps, allergic nasal crease,
halitosis, tonsillar hypertrophy, pharyngeal cobblestoning, high arched or cleft palate,
hoarseness
●Tympanic membrane scarring or frank otorrhea
●Abnormal heart sounds, abnormal pulses
●Hepato- and/or splenomegaly, abdominal masses, bloating, rectal prolapse
●Edema of the extremities, cyanosis and/or clubbing of the digits
●Rashes and other skin lesions (eg, scars of healed recurrent impetigo)
●Neurologic abnormalities
●Dysmorphism or other evidence of a genetic syndrome
Chest examination — The characteristics of the cough should be observed, first if it occurs
spontaneously during the interview, and if not, then during a voluntary cough maneuver. These
characteristics are an important factor in determining the diagnostic approach. (See 'Diagnostic
approach' above.)
Chronic cough and wheeze are often noted in combination. Even in the absence of a history of
wheeze, clinicians should pay close attention to any evidence of this finding on physical
examination.
Polyphonic wheezing (ie, many different pitches) with cough is typical of asthma; the wheezing
occurs on expiration and sometimes also on inspiration. Many children with asthma are also
atopic and exhibit signs of rhinitis, conjunctivitis, and/or eczema [23]. Other causes of
polyphonic wheezing include viral bronchiolitis, obliterative bronchiolitis, bronchiectasis (cystic
fibrosis, allergic bronchopulmonary aspergillosis, primary ciliary dyskinesia), bronchopulmonary
dysplasia, heart failure, immunodeficiency, bronchomalacia, and aspiration syndromes.
Monophonic wheezing (a single, distinct noise of one pitch and starting and stopping at one
discrete time) and cough should always raise suspicion of large airway obstruction caused by
foreign body aspiration or malaciaand/or stenosis of the central airways. The wheeze of large
airway obstruction can often be heard without a stethoscope. In addition, vascular rings,
lymphadenopathy, and mediastinal tumors can cause extrinsic large airway obstruction.
Tuberculosis should always be considered in a child with a monophonic wheeze, particularly in
areas where the disease is prevalent [36]. In children with tuberculosis, wheezing is probably
caused by extrinsic compression of the central airways from contiguous hilar adenopathy.
(See "Approach to wheezing in infants and children" and "Assessment of stridor in children".)
CHEST RADIOGRAPHY — In addition to a thorough history and physical examination, a chest
radiograph should be obtained. If foreign body aspiration is suspected because of the age,
clinical presentation or history, frontal films should be obtained during both inspiration and
expiration, to evaluate for unilateral lung hyperinflation that would suggest airway obstruction.
Similar information can be obtained from the combination of frontal, right lateral decubitus, and
left lateral decubitus radiographs.
A definitive diagnosis is rarely made on the radiographic findings alone, but the following
radiographic appearances lend some support to specific diagnoses, and may be helpful in
determining the sequence of subsequent diagnostic tests:
●Normal chest radiograph – This is typical in habit cough. However, patients with a variety
of pathological conditions, including foreign body, asthma, early cystic fibrosis, and
bronchiectasis, can also have normal chest radiographs.
●Bilateral peribronchial accentuation ("cuffing") with or without hyperinflation – This finding
suggests diffuse airway inflammation or infection, and can be seen in patients with asthma,
cystic fibrosis, protracted bacterial bronchitis, chronic aspiration, and primary ciliary
dyskinesia.
●Bilateral peribronchial accentuation with one or more focal consolidated infiltrates – These
findings are also seen with diffuse airway inflammation, including asthma, protracted
bacterial bronchitis, or disorders of impaired airway clearance (eg, ciliary dyskinesia and
cystic fibrosis). Infiltrates are most commonly seen in the right middle lobe.
●Asymmetry in aeration or vascular markings – These findings suggest the possibility of
partial airway obstruction, such as from a foreign body, vascular compression, or bronchial
stenosis.
●Right middle lobe infiltrates – This distribution is frequently seen in patients with
obstructive airway disease; it reflects atelectasis and appears in the right middle lobe
because the collateral ventilation in this lobe is underdeveloped in comparison to the other
lobes.
●Peribronchial accentuation with associated macronodularity and/or linear infiltrates
emanating from the hilum – This appearance is consistent with bronchiectasis. Other
findings in bronchiectasis are linear atelectasis, dilated and thickened airways (ie, tramtracking or parallel lines, ring shadows on cross section) (image 1A-B), and irregular
peripheral opacities that may represent mucopurulent plugs. (See"Causes of chronic cough
in children", section on 'Chronic suppurative lung disease and bronchiectasis'.)
●Hilar adenopathy – This finding raises the possibility of mycobacterial or fungal infection
(table 3), sarcoidosis, or tumor.
●Mediastinal widening – This finding in children suggests chronic infection, marked
lymphadenopathy, or neoplasm. In an infant or young child, the most common cause of
mediastinal is a normal thymus (image 2). If the structure is not readily identified on plain
film, it can be further characterized by ultrasound, computerized tomography, or magnetic
resonance imaging [37,38].
●A large or abnormally shaped heart – This suggests a primary cardiac defect. A large
pulmonary artery may be caused by primary or secondary pulmonary hypertension.
●Abnormalities of the pleura – Pneumothorax, pleural effusion, and pleural thickening all
suggest underlying lung disease.
PULMONARY FUNCTION TESTS — Spirometry will show signs of obstruction in diseases that
obstruct the airways, and restriction in interstitial or chest wall restrictive processes. Suboptimal
effort on the part of the child will also result in a restrictive picture; thus, spirometry should be
conducted by a technician proficient in testing children.
If an obstructive pattern is seen on the expiratory flow-volume loop, the reversibility of the
obstruction can be assessed by measuring FEV1 before and after inhalation of a
bronchodilating agent. A positive response to bronchodilators establishes the presence of
airway reactivity, and is suggestive of asthma but does not rule out other disorders. As an
example, children with cystic fibrosis often respond to bronchodilators [39]. Abnormalities on the
inspiratory loop correlate with extrathoracic airway obstruction, more often associated with
stridor than cough. (See "Overview of pulmonary function testing in children".)
BRONCHOSCOPY — The primary indication for urgent bronchoscopy in children with chronic
cough is for suspected foreign body aspiration. This diagnosis should always be considered,
even in the absence of obvious findings, especially in younger children and/or if there is a
history of a choking episode preceding the onset of symptoms. (See "Airway foreign bodies in
children".)
Bronchoscopy is also valuable in the evaluation of suspected airway malacia,
tracheoesophageal fistula, or stenosis. Patients with presumed infectious etiologies in whom a
sputum sample is not obtained or yields negative results can be evaluated with flexible
bronchoscopy to perform bronchoalveolar lavage for bacterial, fungal, and mycobacterial
cultures. Bronchial brushings can also be taken for patients with suspected ciliary dyskinesia,
although nasal brushings also may be used. (See "Primary ciliary dyskinesia (immotile-cilia
syndrome)", section on 'Diagnostic evaluation'.)
OTHER TESTS — Additional evaluation depends upon the diagnosis (or diagnoses) being
considered (table 2) [40].
Esophageal pH monitoring — Whether gastroesophageal reflux disease (GERD) is an
important cause of isolated chronic cough in children is controversial. Most authorities suggest
that this is not a common cause except in association with neurologic abnormalities
predisposing to aspiration [5]. (See "Causes of chronic cough in children", section on
'Gastroesophageal reflux'.)
For patients with features strongly suggestive of GERD, esophageal pH monitoring and/or an
empiric trial of treatment for GERD may be undertaken. (See "Clinical manifestations and
diagnosis of gastroesophageal reflux disease in children and adolescents".)
Sinus imaging — Most authorities suggest that sinusitis is not a common cause of chronic
cough in children except in association with an immune defect predisposing to chronic infection
[2,5]. Historical series in which sinusitis was diagnosed on the basis of response to antibiotics
may have included cases of protracted bacterial bronchitis, which would also respond to
antibiotics, or patients who would have improved even without antibiotics. (See "Causes of
chronic cough in children", section on 'Upper airway cough syndrome'.)
For patients with clinical features strongly suggestive of sinusitis (eg, mucopurulent drainage,
chronic nasal obstruction, or facial pain or pressure), imaging of the sinuses and/or an empiric
trial of treatment for sinusitis may be undertaken. However, the results should be interpreted
with caution, because there is poor correlation between sinus radiography or computerized
tomography and clinical disease [2,41]. Imaging reveals some sinus abnormality in 20 to 80
percent of asymptomatic patients. (See "Acute bacterial rhinosinusitis in children: Clinical
features and diagnosis", section on 'Radiologic features'.)
Tuberculin testing — The presentation of tuberculosis may be subtle in children. Therefore,
tuberculin skin testing should be considered, even in the absence of obvious signs and
symptoms, particularly if the child is at high risk for exposure. (See "Latent tuberculosis infection
in children" and "Tuberculosis disease in children".)
Allergy testing — In preschool children, skin prick testing or radioallergosorbent testing (RAST)
for defining the presence of atopy may be indicated and, when positive, increases the likelihood
that the child has asthma. (See "Overview of skin testing for allergic disease".)
INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials,
"The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain
language, at the 5th to 6th grade reading level, and they answer the four or five key questions a
patient might have about a given condition. These articles are best for patients who want a
general overview and who prefer short, easy-to-read materials. Beyond the Basics patient
education pieces are longer, more sophisticated, and more detailed. These articles are written
at the 10th to 12th grade reading level and are best for patients who want in-depth information
and are comfortable with some medical jargon.
Here are the patient education articles that are relevant to this topic. We encourage you to print
or e-mail these topics to your patients. (You can also locate patient education articles on a
variety of subjects by searching on "patient info" and the keyword(s) of interest.)
●Basics topic (see "Patient education: Cough in children (The Basics)")
SUMMARY AND RECOMMENDATIONS
●There is no consensus definition of the time frame for chronic cough in children. Chronic
cough is often defined as a cough lasting more than four weeks, because most acute
respiratory infections in children resolve within this interval. Other schemes define chronic
cough as one that last more than eight weeks but also recognize that a relentlessly
progressive cough often warrants evaluation prior to eight weeks. (See'Definition' above.)
●Chronic cough can be a symptom of congenital anomalies, genetic disease, airway
obstruction, infection, airway inflammation without infection (as in asthma), neoplasia, or
psychogenic processes (table 1). (See'Specific cough' above and "Causes of chronic
cough in children".)
●The evaluation of a child with chronic cough should include a detailed history, physical
examination, chest radiograph, and spirometry (when possible). (See 'Diagnostic
approach' above.)
●Symptoms and signs that are highly predictive of a specific cough include chronic wet
cough, wheezing or crepitations, onset after a choking episode, abnormal chest
radiography or spirometry, associated cardiac or neurologic abnormalities, and failure to
thrive, feeding difficulties, or hemoptysis. These signs or symptoms narrow the diagnostic
possibilities and call for further specific testing or referral (algorithm 1). (See 'Key
symptoms and signs' above.)
●The symptom of a chronic wet cough in a young child usually indicates protracted
bacterial bronchitis (PBB) or retained foreign body. Young children with a chronic wet
cough should be evaluated to exclude the possibility of an aspirated foreign body. Children
with suspected PBB should be treated with antibiotics, usually selected empirically.
(See 'Key symptoms and signs' above and "Causes of chronic cough in children", section
on 'Protracted bacterial bronchitis'.)
●A chronic cough that first began after an episode of choking, or that began suddenly while
eating or playing (especially in a preschool-aged child), suggests the possibility of foreign
body aspiration. (See 'Age and circumstances at onset' above and "Airway foreign bodies
in children".)
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