The management of cough in children should be etiologically based. This requires that all children with cough should be carefully evaluated and managed differently than adults because the etiologic factors and treatment in children are significantly different than that in adults. In all children with cough, exacerbation factors should be sought and intervention options for cessation advised or initiated. Parental expectations and specific concerns should also be sought and addressed.
Keywords
The prevalence of chronic cough (5%–10%)
1
, 2
is likely dependent on the setting, age of the cohort studied, instrument used, and definition of chronic cough.3
Cough as a symptom is almost ubiquitous for the entire respiratory system, ranging from uncomplicated minor respiratory tract infections (RTI) to major illnesses, such as cystic fibrosis. Rarely, it may be a symptom of extrapulmonary disease, such as cardiac abnormalities. Most acute cough in children is related to RTIs. Not surprisingly, cough is often trivialized. Cough, however, especially when chronic, significantly impacts on parents' quality-of-life scores.4
, 5
The burden and brief pathophysiology of cough
The burden of cough is also reflected in the billions of dollars spent annually on over-the-counter (OTC) cough medications,
6
and the number of consultations sought for cough. In an Australian study, the number of medical consultations for coughing illness in the last 12 months was high: more than 80% of children had greater than or equal to five doctor visits, and 53% had greater than 10.5
Parents of children with chronic cough did not have symptoms of anxiety or depression but were stressed.5
This is in contrast to adults with chronic cough, which is associated with the presence of depression and anxiety.7
, 8
Clinicians need to be cognizant of the stress parents have when dealing with children with chronic cough. The reasons for parental fears and concerns included cause of the cough, fear of choking, and long-term respiratory damage.1
, 5
, 9
Physiologically, cough has three phases: (1) inspiratory, (2) compressive, and (3) expiratory.
10
The inspiratory phase consists of inhaling a variable amount of air, which serves to lengthen the expiratory muscles, optimizing the length-tension relationship. The compressive phase consists of a very brief (200 millisecond) closure of the glottis to maintain lung volume as intrathoracic pressure builds (up to 300 mm Hg in adults) because of isometric contraction of the expiratory muscles against a closed glottis. The expiratory phase starts with opening of the glottis, releasing a brief (30–50 millisecond) supramaximal expiratory flow11
(up to 12 L/s in adults, also termed the “cough spike”) followed by lower (3–4 L/s) expiratory flows lasting a further 200 to 500 millisecond.10
Dynamic compression of the airways occurs during the expiratory phase and the high-velocity expulsion of gas (air) sweeps airway debris along. Airway debris and secretions are also swept proximally by ciliary activity. Cough also enhances mucociliary clearance in both healthy individuals and those with lung disease.12
Cough can be voluntarily initiated or suppressed, except when it is part of the laryngeal expiratory reflex when the larynx is mechanically stimulated by foreign materials. Physiologists describe two basic types of cough: laryngeal cough (a true reflex, also known as “expiratory reflex”) and tracheobronchial cough. Laryngeal cough protects the airways from airway aspiration. Tracheobronchial cough is initiated distal to the larynx and can be volitional. It is primarily stimulated by chemoreceptors in the lower airways and can also be mechanically stimulated.
3
The primary function of tracheobronchial cough is airway clearance and maintenance of the mucociliary apparatus. It has been argued that differentiating the types of cough and what constitutes as a cough is important.13
Clinicians remain certain, however, what cough is in the clinical setting.The knowledge of cough neurophysiology has significantly advanced in recent years, although much of the work is based on animal models and may have limited applicability to humans because significant interspecies differences exist.
14
Readers are referred to recent reviews14
, 15
, 16
, 17
for in-depth aspects of cough-related neurophysiology. As a gross oversimplification, the cough pathway can be compartmentalized to the afferent arms (from cough stimulus to the respiratory center) and efferent arms (from respiratory center to respiratory muscles, larynx, and pelvic muscles) of the cough pathway; they are likely to be influenced by a bidirectional feedback loop, but this has not yet been clearly established. Receptors involved in cough are terminations of vagal afferents in airway mucosa and submucosa.14
, 18
, 19
These afferent receptors have different sensitivity to different stimuli and are unequally distributed in the airways; generally, the larynx and proximal large airways are more mechanosensitive and less chemosensitive than peripheral large airways. The existence of distinct cough receptors, widely assumed to be present and first proposed by Widdicombe,20
was only recently proved.15
, 18
Generation of action potentials (depolarization of the terminal membrane) from these receptors is subclassified into ionotropic receptors (they cause generator potentials by acting on ligand-gated ion channels) and metabotropic receptors (they act indirectly on ligand-gated ion channels by G-protein coupled receptors).17
, 21
These cough and airway receptors mediated through the vagus nerve, jugular, and nodose ganglions extend to the nucleus tractus solitaris, which is the first central nervous system synaptic contact of these afferent fibers.
22
Second-order neurons from the nucleus tractus solitaris have polysynaptic connections with the central cough generator, which is also the respiratory pattern generator.16
, 22
Nucleus tractus solitaris is postulated to be the site of greatest modulatory influence and plasticity. The mechanisms underpinning chronic cough have been likened to that of chronic pain,3
and increased neurogenic markers have been described in children with increased cough receptor sensitivity.23
The intrathoracic pressure and effects of it generated by cough may also perpetuate the chronic cough cycle as suggested by a recent animal study that showed pressure effects enhance cough sensitivity.24
An effective cough is dependent on generation of high linear velocities and interaction between flowing gas and mucus in the airways.
10
This is dependent on the integrity of the mechanisms described previously. Other physical characteristics also influence cough efficiency: adequate airway caliber (efficiency decreased in presence of flow-limitation25
[eg, severe tracheomalacia]); mucous physical properties (sputum tenacity, adhesiveness, water content, and so forth);10
and respiratory muscle strength.10
The importance of the integrity of the cough reflex is reflected when it is impaired. Aspiration lung disease occurs in those with a dysfunctional laryngeal reflex (eg, central neurologic problems and multiple organ dysfunction).26
When the muscular apparatus for an effective cough is impaired (eg, muscular dystrophy), recurrent mucus retention and atelectasis occurs.Management of the symptom of cough
The overall management of cough entails an evaluation for the following: (1) etiology, which includes assessing if further tests or treatment are required; (2) defining exacerbation factors (eg, exposure to environmental tobacco smoke); and (3) defining the effect on the child and parents.
Defining the Etiology of the Cough
The most likely etiology depends on the setting, selection criteria of children studied, follow-up rate, depth of clinical history, examination, and investigations performed. In defining the etiology, it is helpful to define cough types in accordance to different constructs. Pediatric cough can be classified in several constructs based on (1) timeframe (acute, chronic); (2) likelihood of an identifiable underlying primary etiology (specific and nonspecific cough); and (3) characteristic (moist versus dry). For clinical practicality timeframe is commonly used, divided into acute (<2 weeks), subacute (2–4 weeks), and chronic (>4 weeks) cough. There are no studies that have clearly defined when cough should be defined as chronic (variably defined from >4–8 weeks).
27
, 28
, 29
Cough related to an upper RTI resolves within 10 days in 50% of children and by 25 days in 90%;30
arguably, childhood chronic cough should be defined as persistent daily cough of greater than 4 weeks. Chronic cough is further subdivided into specific cough (cough associated with other symptoms and signs that are suggestive of an associated or underlying problem) and nonspecific cough (dry cough in the absence of any identifiable respiratory disease or known etiology). These classifications, however, are not mutually exclusive.Acute cough and expected cough
Although acute RTIs are the most common cause of acute cough in children, all children should be assessed for symptoms and signs of more serious cause, such as inhaled foreign body. In 8% to 12% of children with upper RTIs complications develop.
30
These conditions are discussed elsewhere in this issue.Expected cough is the presence of cough in situations where cough is the norm, such as during an acute respiratory infection. In most children, acute cough is self-limiting and treatment, if any, should be directed at the cause rather than the symptom of cough. OTC medications for cough confer no benefit in the symptomatic control of cough or on the sleep pattern of children or parents and may cause harm. Steam inhalation, vitamin C, zinc, and Echinacea for upper RTI have little benefit, if any, for symptomatic relief of cough. Systematic reviews have also shown that oral or inhaled β2-agonists also confer no benefit in children with acute cough and no evidence of airflow obstruction. Antimicrobials are nonbeneficial in acute cough associated with colds. In contrast, honey (0.5–2 teaspoons depending on age) has been shown to be useful in reducing nocturnal cough and improving sleep quality of parents and children with an acute upper RTI-associated cough (Table 1).
31
Subacute and chronic cough
Chronic cough differs from acute cough in its management and etiologic factors. The timeframe chosen for chronic cough is similar in the Australian
27
and American28
guidelines, but differs from the British guidelines.29
The difference likely reflects the lack of evidence. It is unknown whether the primary stimulus for chronic cough in many children is identical to that for acute cough. Further, it is unknown why the cough associated with common acute viral upper RTIs resolves in most, yet persists in some. Presumably, however, both the specific microbe (eg, cough is more likely to be prolonged after a potent respiratory infection, such as pertussis) or host factors (eg, genetic predisposition to bronchitis) play a role. Unfortunately, there are no studies that have clearly defined when cough should be defined as chronic. Studies have shown that cough related to upper RTIs resolves within 1 to 3 weeks in greater than 90% of children.30
, 32
It is logical to define chronic cough as daily cough lasting greater than 4 weeks; published definitions of chronic cough in children have varied from 3 to 12 weeks.33
In contrast, the current definition of chronic cough in adults is 8 weeks. The pediatric definition is based on the natural history of acute upper RTIs in children30
, 32
and the knowledge that pediatric respiratory illness has important differences than that in adults.33
For example, such conditions as a missed foreign body, which is more common in children (especially in those aged ≤5 years), can lead to permanent lung damage.34
Classically recognizable cough
Certain cough characteristics, such as “croupy or brassy cough,” are classically taught to point to specific etiologies in children. Data on the sensitivity and specificity of each classic recognizable cough type are limited; the data for brassy cough (for tracheomalacia diagnosed at bronchoscopy) were 0.57 and 0.81, respectively.
35
Kappa value for interobserver agreement for brassy cough was good at 0.79 (95% confidence interval [CI], 0.73–0.86).35
Although a pertussis-like cough in children is generally caused by Bordetella pertussis infection, it may also be caused by adenovirus, parainfluenza viruses, respiratory syncytial virus, and mycoplasma.36
By contrast, the quality of cough has been shown to be of little use in adults.37
Chronic productive purulent cough is always pathologic. In obtaining a history in a child with chronic cough, questions specific for classically recognizable cough, such as an exposure to illness history (eg, pertussis and tuberculosis), should be obtained.Wet-moist-productive cough versus dry cough
Even when airway secretions are present, young children rarely expectorate sputum; hence, “wet-moist” cough is the preferable term rather than “productive” cough.
38
, 39
The distinction of dry and wet-moist cough has been shown to be both valid and reliable. In a study of 106 children, cough quality (wet or dry) assessed by clinicians had good agreement with parents' assessment (K = 0.75; 95% CI, 0.58–0.93), and had good sensitivity (0.75) and specificity (0.79), when compared with bronchoscopy findings.35
The use of wet versus dry cough for predicting etiology of cough or response to treatment has not been shown in children, except in protracted bronchitis.40
Specific and nonspecific chronic cough
Clinical signs and symptoms that are suggestive of an underlying pulmonary or systemic disorder are termed “specific cough pointers” (Box 1).
27
When any of these pointers are present, the cough is referred to as “specific cough.” If specific cough pointers are present, further investigations and management of the primary pulmonary pathology is usually warranted. If not, a counsel, watch, wait, and review approach is suggested. This approach is suggested for nonspecific cough (dry cough in the absence of specific cough pointers). Such cough is more likely to undergo natural resolution.41
A dry cough may be the early phase of a wet cough,42
however, and children should be reviewed and attention to exacerbation factors and parental concerns (see later) are warranted.Box 1
Pointers for presence of specific cough
- Auscultatory findings (wheeze, crepitations or crackles, differential breath sounds)
- Cough characteristics (eg, cough with choking, cough quality, cough starting from birth)
- Cardiac abnormalities (including murmurs)
- Chest pain
- Chest wall deformity
- Daily moist or productive cough
- Digital clubbing
- Dyspnea (exertional or at rest)
- Exposure to pertussis, tuberculosis, and so forth
- Failure to thrive
- Feeding difficulties or dysphagia (including choking or vomiting)
- Hemoptysis
- Immune deficiency
- Medications or drugs (angiotensin-converting enzyme inhibitor)
- Neurodevelopmental abnormality
- Recurrent pneumonia
In selected children with nonspecific cough, diagnoses with simple treatment options, (eg, asthma and complications of upper RTIs, such as sinusitis and bronchitis) may be considered. The evidence for the association between asthma
3
, 43
and upper airway disorders and cough is not as straightforward in children, however, as it is in adults.33
, 44
The use of isolated cough as a marker of asthma is controversial with more recent evidence (clinical and community epidemiologic studies) showing that in most children, isolated cough does not represent asthma.3
, 45
Investigations
As a minimum, all children with chronic cough should have a spirometry (if age appropriate) and chest radiograph performed.
27
, 28
The validity of this has been shown.41
When a chest radiograph taken for chronic cough is abnormal, the odds ratio of an specific etiology was 3.16 (95% CI, 1.32–7.62).41
Other tests to identify the etiology of nonspecific cough have limited applicability in pediatrics. Identification of airway hyperresponsiveness, diagnostic for asthma in adults, is of limited use in children because of interpretation difficulties, and reliable tests can only be performed in older children in whom cough is less common. The three most common causes of chronic cough in adults (gastroesophageal reflux disease, asthma, and upper airways syndrome)46
are not as common in children.47
Increased cough sensitivity is found in most conditions causing chronic cough but its use is limited to research.28
Except when classical asthma is the etiology, children with specific cough usually require additional tests (chest high-resolution CT scan, bronchoscopy, video fluoroscopy, echocardiograph, sleep polysomnography, nuclear medicine scans, immunologic assessment, and so forth). The role of these tests for evaluation of lung disease is beyond the scope of this article because it encompasses the entire spectrum of pediatric respiratory illness.
Medications
Treatment for subacute and chronic cough should be etiologically based, and that for specific cough is beyond the scope of this article. Cough is subjected to the period-effect (ie, spontaneous resolution of cough); the benefit of placebo treatment for cough has been reported to be as high as 85% and non–placebo-controlled intervention studies have to be interpreted with caution.
3
Evidence (or lack of) on treatment trials for nonspecific cough are summarized in Table 1. Systematic reviews have concluded that OTC cough remedies have little benefit in the symptomatic control of childhood cough. Significant morbidity and mortality48
from OTC cough remedies can occur and OTC drugs are common unintentional ingestions in children aged less than 5 years.49
Cochrane reviews on symptomatic treatment of cough have shown that diphenhyramine is not beneficial for pertussis-related cough; cromones and anticholinergics have little, if any, role in nonspecific chronic childhood cough; and 10 days of antimicrobials reduces persistent cough in children with chronic nasal discharge but benefits are modest (number needed to treat was 8). Antimicrobials may be indicated for subacute and chronic moist cough; two randomized controlled trials (RCTs) showed predominance of Moraxella catarrhalis. Meta-analysis on antimicrobials for acute bronchitis in older children (aged >8 years) and adults showed a small benefit of 0.58 days but with significantly more adverse events. Systematic review of uncomplicated sinusitis in children showed that the clinical improvement rate was 88% with antimicrobial and 60% on no antimicrobial. There are only two published RCTs on inhaled corticosteroids for nonspecific cough in children and both groups cautioned against prolonged use.50
, 51
In the North American guidelines for pediatric gastroesophageal reflux, the conclusion on cough and gastroesophageal reflux disease section was “there is insufficient evidence and experience in children for a uniform approach to diagnosis and treatment.”52
If medications are trialed for nonspecific cough, the child should be reviewed and time to response considered. For example, in asthma-related cough, earlier non-RCT studies in adults and children that used medications for asthma for the era (ie, nonsteroidal anti-inflammatory drugs, theophylline, terbutaline, major tranquillizers) reported that cough completely resolved by 2 to 7 days.
3
Time to response is defined as the expected length of time cough resolution occurred in studies where the cough treated was related to the etiology defined.Defining Exacerbation Factors
When reviewing any child with cough irrespective of the etiology, exacerbation factors should be explored, although no RCTs have examined the effect of cessation of environmental pollutants on cough. There is little doubt that children with environmental tobacco smoke exposure have increased risk of having chronic
53
, 54
and recurrent cough.55
The American Academy of Pediatrics policy on tobacco includes recommendations for tobacco cessation.56
Other exacerbation factors include exposure to pollutants and secondary gains from having a cough.Defining Effect on Child and Parent
Parents presenting to doctors for their children's cough have significant concerns that causes parental stress.
5
The most significant concerns and worries expressed by parents are feelings of frustration, upset, sleepless nights, awakened at night, helplessness, stress, and feeling sorry for the child. Items that bothered the parents most were the cause of cough, cough relating to a serious illness, child not sleeping well, and cough causing damage.5
Previous studies have described parental fears of their child dying from choking, asthma attack, or cot death, and permanent chest damage, disturbed sleep, and relief of discomfort.1
, 9
These concerns are often not appreciated by health professionals and exploration of parental expectations and fears is valuable when managing a child with a chronic cough.Providing parents with information on the expected time length of resolution of RTIs may reduce anxiety in parents and the need for medication use. Parental and professional expectations and doctors' perception of patients' expectations influences consulting rates and prescription of medications in RTIs. Educational input is best done with consultation about the child's specific condition because written information without consultation has only modest benefit in changing perceptions and behavior. It is also known that information available from the Internet provides incorrect advice on the home management of cough in children.
Summary
Box 2 lists the steps to take when a child with chronic cough presents to the clinician.
Box 2
When a child with chronic cough presents
- 1.A complete medical examination with particular attention to the cardiorespiratory systems and a focus on
- a. The clinical pattern
- Characteristic cough (eg, pertussis, tracheomalacic cough, see Box 1)
- Wet or dry cough? Protracted bronchitis?
- Presence of specific cough pointers to differentiate specific from nonspecific cough, (Table 2) (GRADE, moderate; Level of evidence, cohort studies)41,47Table 1Recommendations for possible interventions for nonspecific cough in children
Therapy Recommendation Grade Type and Strength of Evidence Time to Response Antihistamines Nonsedating Not generally recommended unless symptoms of rhinitis coexist Moderate SR with RCTs 57,581 wk Sedating Sedating antihistamines should not be used, strong Not relevant Antimicrobials For wet cough only, strong High SR with RCTs 401–2 wk Asthma-type therapy Cromones Not recommended, weak Very low SR with single open trial 592 wk Anticholinergics Not recommended, weak Very low SR, no studies in children RCTs 60No data Inhaled CS Not generally recommended unless symptoms of asthma present, strong Moderate SR with RCTs 50,512–4 wk Oral CS Not recommended, weak Low No data β2-agonist (oral or inhaled) Not generally recommended unless symptoms of asthma present, weak Moderate SR with RCTs 61RCT50Not relevant Theophylline Not recommended, weak Very low SR, no studies 621–2 wk Leukotriene receptor antagonist Not recommended unless symptoms of asthma present, weak Very low SR, observational study 632–3 wk GERD therapy Motility agents Not recommended as empiric therapy, weak Very low SR with single trial 64Not relevant Acid suppression Not recommended as empiric therapy, weak Very low SR with no RCTs in children 64Food-thickening or antireflux formula Consider if other symptoms of reflux present (infants only), weak Moderate SR with RCTs 641 wk Fundoplication Systematic review 64Herbal antitussive therapy Not recommended, weak Very low No data Nasal therapy Nasal steroids Not generally recommended unless symptoms of rhinitis coexist, weak Low RCT 65Beneficial when combined with antibiotics for sinusitis661–2 wk Other nasal sprays Not recommended, strong Very low No data Over-the-counter cough medications Not recommended, strong High SR with RCTs 57,67,68,69Not relevant Other therapies Steam, vapor, rubs Consider rubs but not vapor or steam, weak Low No data Honey Recommended if no contraindications for using of honey, strong Moderate Single RCT on acute cough 311 d Physiotherapy Not recommended unless cough related to suppurative lung disease, weak Very low No data in cough that is unrelated to suppurative-like lung diseases Abbreviations: CS, corticosteroids; GERD, gastro-esophageal reflux disease; RCT, randomized controlled trials; SR, systematic review.a Grading of evidence and recommendations.70b Length in time for cough to resolve or substantially improve as reported by trialists.Table 2Characteristic or classical types of coughCough Type Suggested Underlying Process Barking or brassy cough Croup, tracheomalacia, habit cough Honking Psychogenic Paroxysmal (± inspiratory “whoop”) Pertussis and parapertussis Staccato Chlamydia in infants Cough productive of casts Plastic bronchitis or asthma Chronic wet cough in mornings only Suppurative lung disease Data from Chang AB, Glomb WB. Guidelines for evaluating chronic cough in pediatrics: ACCP evidence-based clinical practice guidelines. Chest 2006;129:260S–83S; and Chang AB. Causes, assessment and measurement in children. In: Chung KF, Widdicombe JG, Boushey HA, editors. Cough: causes, mechanisms and therapy. London: Blackwell Science; 2003. p. 57–73. - b. Presence of exacerbation factors (eg, environmental tobacco smoke, curtailment of physical activity)
- c. Effect of the cough on the child and parents, and explore their concerns (see previously) (GRADE, moderate; Level of evidence, cohort studies)
- 2.All should undergo
- Chest radiograph
- Spirometry (if aged >3 years) (GRADE, moderate; Level of evidence, cohort studies)
- 3.They should be further investigated and likely require referral if
- Specific cough pointers are present (other than asthma) (see Table 2)
- Cough has not resolved with treatment trials (GRADE, moderate; Level of evidence, cohort studies)
- 4.A “wait, reassess, and review” approach is recommended for children with nonspecific cough because medications are generally not efficacious for nonspecific cough (see Table 1). If medications are trialed, a reassessment is recommended in 2 to 3 weeks, which is the time to response for most medications.27,28(GRADE, moderate; Level of evidence, cohort studies and RCTs)
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Article info
Footnotes
A.B. Chang is funded by the Royal Children's Hospital Foundation and the National Health and Medical Research Council, Australia.
Identification
Copyright
© 2009 Elsevier Inc. Published by Elsevier Inc. All rights reserved.
