By Pharm. (Mrs) Timeyin Ogungbe

Children who cough are frequently seen in community practice. Determining what is “normal” cough from that which is abnormal can be challenging for both parents and primary care teams. Cough is a protective reflex and children who have no evidence of illness may cough an average of 11 times over a day. (1)

Children are not small adults and the causes of cough in children may be different to the causes in adults. (2,3). The assessment of children with cough, particularly when the cough is chronic, should be carried out in a systematic way. This should assist with the formation of an accurate diagnosis whenever possible and then allow successful management of the cough.

There are 3 key aspects of assessment that can be done within the context of community pharmacy practice to determine the nature of children’s cough.

1. Listen to the concerns of parents.
2. Consider personal, family history and environmental factors
3. Ask key questions

1. Listen to the concerns of parents. Cough in children, regardless of the underlying reason, can cause significant distress, disruption of daily activities and a lack of sleep for both the child and the parents. Ask open questions following the standard “FIFE” format such as:

• Feelings: What are your concerns?
• Ideas: What do you think is the cause of the cough?
• Function: How is the cough affecting your child and yourself?
• Expectations: What do you think is needed to help resolve the cough?

Responses to these questions should help uncover parental concerns, suggest areas requiring further direct questioning and guide the type and range of advice given. In many cases the answers may also reveal the likely diagnosis.

2. Consider personal, family history and environmental factors

Aspects of the child’s personal, family and social history may provide clues to the underlying reason for a cough. Ask about:

• The child’s personal medical history e.g. a history of atopy, recurrent infections, poor growth
• The family history (particularly a history of any respiratory conditions)
• Any exposure to environmental factors e.g. cigarette smoke, animals, damp living conditions
• The immunization status of the child and others in the family
• Tuberculosis (TB) if there is any history of contact with a person with TB.

Take the opportunity to measure height and weight, to provide advice about a smoke-free home or to check oral health.

3. Ask key questions

Determining the cause of a cough may not always be straight forward, particularly if the cough becomes chronic (persisting for more than four to six weeks). If the responses to initial open questions have raised concerns then further direct questioning is required. There are several key considerations that may be useful to help make an accurate diagnosis in children with cough. These include:

1. How long has the child been coughing?
2. What does the cough sound like?
3. Is the cough wet or dry?
4. Does the child cough at night?
5. What is the age of the child?
6. Are there any associated symptoms?
7. What triggers the cough?

We shall now look at each of these questions and explain the rationale behind them.

1. How long has the child been coughing?

Cough in children can be categorised as:

1. Acute cough – lasting for less than two weeks
2. Sub-acute or persistent cough – lasting two to four weeks

iii.  Chronic cough – lasting for more than four weeks

Acute and sub-acute cough in children is usually due to a viral respiratory tract infection that will spontaneously resolve within one to three weeks in 90% of children. (4)

Other serious causes of acute coughs e.g. pneumonia, pertussis, foreign body inhalation should however, be considered and excluded, if possible. The acute cough may also indicate the start of a chronic cough condition. In some cases, chronic cough lasting more than four weeks is caused by recurrent viral infections during the cold season, each incompletely resolving before the next infection. A careful history should distinguish this from true chronic cough. Children with chronic cough are likely to require review as the underlying cause of the cough may not initially be clear and the type of cough may change over time.

It is also important to ask about the onset of the cough. Cough associated with  very sudden onset or a history of choking may suggest inhalation of a foreign body, particularly in younger children.

1. What does the cough sound like?

The character or the quality of the cough may in some cases suggest a specific cause, termed as classically recognised cough (Table 1).

However, in practice this may have limited value. Unless the child is coughing within the pharmacy, the Community Pharmacist is dependent on a description of the cough from the parents.

Other causes should not be excluded on this basis alone e.g. a “pertussis like” paroxysmal cough may be due to Bordetella pertussis but could also be caused by a viral infection such as adenovirus, parainfluenza virus, respiratory syncytial virus (RSV) or mycoplasma.

The age of the child may also alter the character of cough e.g. infants aged under six months with pertussis do not usually “whoop”.

1. Is the cough dry or wet?

Determining whether the cough is dry and irritating or wet and “rattly” may help to diagnose the cause, particularly if the cough is chronic. A chronic cough with purulent sputum in a child requires further assessment as it always indicates underlying disease (5).

A wet cough in older children and adults is often called a “productive” cough, but this term has limited value for many younger children as they tend to swallow sputum rather than cough it up, often resulting in vomiting. It may be more useful to ask if the child has vomited.

Research has shown that subjective reporting of a wet cough by parents is consistent with findings of airway secretions at bronchoscopy (6). A wet cough was shown to be always associated with an increase in airways secretions, however a dry cough did not always signify an absence of secretions. In addition, a dry cough may be reported early in an illness and then evolve into a wet cough as secretions increase (6). Parents should be made aware of when it is appropriate to bring the child back for review and also advised about signs that may suggest worsening illness.

1. Does the child cough at night?

Sleep generally suppresses “normal” and habit cough and although nocturnal cough is often associated with asthma, this is less likely for children in the absence of any other associated symptoms such as wheeze.

Nocturnal cough is often a reason for presentation for medical attention because the cough may cause significant anxiety for the parents, be more noticeable and disturb sleep for the whole family. Although nocturnal cough may be the symptom that drives the parent to bring the child to the GP, evidence suggests that parental reporting of nocturnal cough can be subjective (7).

1. How old is the child?

The age of the child when the cough started may be important in helping determine the diagnosis. Any unexplained persistent cough that begins in the neonatal period (the first 28 days of life) requires investigation and usually indicates significant disease (7). Referral to a paediatrician is usually recommended.

1. Foreign body inhalation

Once children are old enough to put small objects in their mouths, the possibility of aspiration of a foreign body should be considered. Most cases of foreign body aspiration occur in children aged less than four years. Ask parents about the potential for foreign body aspiration, such as access to any small object or consumption of small, smooth foods (e.g. peanuts, raisins, grapes). If foreign body inhalation is suspected then the child should be referred to secondary care for further investigations.

1. Are there any associated symptoms?

Does the child only have a cough or are there other symptoms? The presence of any associated symptoms may help determine the underlying cause of a cough.

Examples may include:

• A cough associated with runny or blocked nose, sore ears or throat, fever or irritability suggests viral infection
• A cough that started after an episode of choking strongly suggests foreign body inhalation
• A cough that is associated with wheezing and breathlessness may suggest asthma
• A history of night sweats and haemoptysis in a “high-risk” child could suggest tuberculosis.

1. What triggers the cough?

Ask about any factors that may trigger the cough e.g. exercise, excitement or cold air. Also ask about environmental factors e.g.:

1. Is the house smoke-free?
2. Are there family pets?

iii.  Is the house damp?

Cough that only appears in specific situations e.g. before speaking, with stress, at school, that disappears at night and that is reproducible upon request may be a habit cough.

Examination

{Generally, in the community pharmacy setting, it may not always be feasible to carry out clinical examination on a coughing child. It is however in order to be aware of the kind of examination that can be carried out.}

The clinical examination of a child who presents with cough should include:

• An assessment of how “well” the child is
• Temperature, hydration, pulse rate and respiratory rate
• Height and weight
• Ear/nose/throat examination – primarily checking for signs consistent with upper respiratory tract infection. N.B. Cough can be triggered in some people by an irritation of the auricular branch of the vagal nerve e.g. by wax or a foreign body in the auditory canal.
• A check for clinical signs suggestive of allergy e.g. allergic “shiners” (dark circles under the eyes), nasal speech, eczema
• Chest examination including observation e.g. accessory muscle use, in-drawing, chest deformity and chest auscultation for localized or generalized chest signs
• A check for digital clubbing.

Investigations for cough

Investigations are not required for children with acute cough who are likely to have a diagnosis of a viral URTI.

Sputum

Sputum culture may be indicated in an older child with a chronic, wet cough. Most young children swallow their sputum and are unable to produce a sample that is of sufficient quality to provide useful results.

Spirometry

Spirometry is indicated for children with chronic, dry cough who are old enough to master the technique (usually school-age children) (8) . Spirometry may give information about airway obstruction and responsiveness to a bronchodilator.

N.B. If the child is asymptomatic and normal results are obtained, this does not exclude a diagnosis of asthma.(14) Peak flow is generally not used as a diagnostic tool for asthma as it has not been validated for this use and results are not repeatable.

Radiography

A chest x-ray should be considered if a child has a:

• Chronic cough of unknown aetiology
• History of aspiration (acute onset of cough, choking episode)
• Persistent signs on chest examination (deformity, focal findings on auscultation)

N.B. A normal chest x-ray does not exclude the presence of an inhaled foreign body.

Management of acute cough in children

The majority of children who present to general practice with acute cough will have a viral URTI. In children without symptoms and signs of a specific serious underlying disease process, the recommended approach is to watch, wait and review. Investigations are not usually required and treatment should be aimed at providing symptomatic relief.

Parents should be given information that enables them to make an informed decision about if and when to bring the child back for review. This may include information on:

• The symptoms to expect
• The duration of these symptoms
• Symptoms and signs of worsening illness
• The plan for follow up
• The potential hazards and ineffectiveness of cough and cold medicines

Among the many children who present with acute cough, it is important to identify the child who may have a predominantly lower respiratory infection and be unwell, with fever, tachypnoea, decreased oxygen saturation and chest signs. Antibiotics may be indicated depending on the diagnosis and a follow up appointment should be arranged to check for clinical improvement and resolution of chest signs. If the child is very unwell, referral for further assessment, chest x-ray and treatment in a secondary care setting may be required.

Management of chronic cough in children

Management of chronic cough depends on the underlying diagnosis. If symptoms and signs found in the history and examination suggest there is a specific underlying disease causing the cough, then treatment should be aimed at this condition. In some cases, the child may need further investigations before a diagnosis can be made.

Causes of chronic cough in children include:

• Persistent respiratory infection including post viral cough, chronic bronchitis, bronchiectasis, cystic fibrosis, pertussis and tuberculosis
• Passive exposure to cigarette smoke
• Asthma
• Recurrent aspiration e.g. secondary to reflux, congenital abnormality
• Habit cough
• Upper airway cough syndrome
• Gastro-oesophageal reflux
• Cardiac causes e.g. congestive heart failure, congenital heart disease
• Medication (9)

Indications for referral

Referral indications for a child with cough include:

• Cough that does not resolve despite simple management
• Suspected foreign body aspiration
• Haemoptysis
• Recurrent pneumonia (or chest signs that do not resolve)
• Suppurative lung disease
• Congenital lung lesions or disease
• Immunodeficiency states
• Cardiac abnormalities

References:

1. Munyard P, Bush A. How much coughing is normal? Arch Dis Child 1996;74:531-4.
2. Chang AB. Cough: are children really different to adults? Cough 2005;1:7.
3. Marchant JM, Masters B, Taylor SM et al. Evaluation and outcome of young children with chronic cough. Chest 2006;129:1132-41.
4. Chang AB, Landau Lim, Van Asperen PP, et al. Cough in children: definitions and clinical evaluation. Position statement of the Thoracic Society of Australia and New Zealand. Med J Aust 2006;184(8):398-403.
5. Goldsobel AB, Chipps BE. Cough in the Pediatric Population. J Pediatr 2010;156(3):352-8.
6. Chang AB, Gaffney JT, Eastburn MM, et al. Cough quality in children: a comparison of subjective vs. bronchoscopic findings. Resp Res 2005;6:3.
7. Chang AB, Newman RG, Carlin JB, et al. Subjective scoring of cough in children: parent-completed vs child-completed diary cards vs an objective method. Eur Respir J 1998;11(2):462-6.
8. Irwin RS, Glomb WB, Chang AB. Habit cough, tic cough, and psychogenic cough in adult and paediatric populations. ACCP evidence-based clinical practice guidelines. Chest 2006:129(1 Suppl):174S-179S.
9. Pattemore PK. Persistent cough in children. N Z Fam Prac 2007;34(6):432-6. alth 2003;39(2):111-7

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