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Peds in Review Cough 2019
Peds in Review Cough 2019
Peds in Review Cough 2019
Practice Gaps
Cough in children is a common chief complaint. It is important to adopt a
systematic approach to the evaluation and management of chronic
cough and avoid symptomatic treatment. The use of pediatric-specific
cough management algorithms improves clinical outcomes.
INTRODUCTION
cough. (19) A daily wet cough can be seen in suppurative casts in a child with congenital heart disease suggests plastic
lung disease from a variety of etiologies, including cystic bronchitis that requires evaluation by a pediatric cardiolo-
fibrosis, primary ciliary dyskinesia (PCD), or other causes of gist and pulmonologist. Recurrent pneumonia can be due to
bronchiectasis. immunodeficiency, suppurative lung disease, congenital
Evaluation of chronic cough should include a discussion lung abnormalities, tracheoesophageal fistula, and other
about the presence of dyspnea. If there is no report of conditions. A detailed feeding history should be obtained
dyspnea at rest, the parent/child should also be asked about in children with chronic cough. An episode of choking or
exertional dyspnea. Exercise is a common trigger for cough acute onset of cough in a child should raise concern for an
and wheezing in children with hyperactive airways. (6) inhaled foreign body. Cough or choking during feeding
Although exertional dyspnea can be associated with asthma, should alert the physician to possible recurrent, small-
it may also suggest airway or parenchymal lung disease volume pulmonary aspiration. The neurodevelopmental
requiring further evaluation. If there is associated chest history should be reviewed because aspiration lung disease
pain, further details regarding the characteristics of the can be seen in children with developmental delays. In the
chest pain should be obtained. If the child has ever had birth history, prematurity and prolonged oxygen require-
hemoptysis, the clinician should evaluate for tuberculosis, ment suggest bronchopulmonary dysplasia, which can
an inhaled foreign body, suppurative lung disease, or vas- cause persistent respiratory symptoms in children. A diag-
cular abnormalities. A history of cardiac abnormalities can nosis of PCD must be considered when there is a history of
be important, as congenital heart disease can be associated neonatal respiratory distress, tachypnea, or a supplemental
with structural airway abnormalities (eg, airway malacia) oxygen requirement in a term infant. (22) Family history
and anatomical compression. (21) Children with congenital should be reviewed for asthma and other chronic respiratory
heart disease can develop cough from congestive cardiac conditions, such as cystic fibrosis or PCD. The social history
failure with pulmonary edema or from respiratory ciliary should assess for environmental factors that can cause
dysfunction due to underlying PCD. Expectoration of airway cough, such as tobacco smoke exposure, indoor pollutants,
cough is typically a dry cough for which no underlying have asthma. (10) An empirical trial of a bronchodilator
etiology is identifiable after a thorough assessment. In most (short-acting b2 agonist) and a low-dose inhaled corticoste-
children, nonspecific cough is due to a viral respiratory infec- roid (ICS) can be administered when asthma is suspected.
tion (postviral cough) that resolves spontaneously with time (1)(9) It can be difficult to exclude asthma as a cause of
and is not due to a serious etiology. (9) Some children can chronic dry cough in young children who are unable to
have a slow recovery of the airway epithelial mucosal cells and perform reliable spirometry, and it may be challenging to
hypersensitivity of the cough receptors after a respiratory identify exertional dyspnea and chest discomfort in young
infection causing prolonged cough. (7) children. A randomized, placebo-controlled trial of inhaled
For most children with nonspecific cough, the initial albuterol and ICSs in children with isolated cough showed
recommended step is a period of watchful waiting for 1 to 2 no benefit of these therapies compared with placebo. (25)
weeks (Table 3). The parents can be reassured, and the child Therefore, it is important that trials of asthma therapy are
can be reevaluated in 2 weeks. At follow-up, the child must effectively administered (using a spacer with a metered-dose
be assessed for persistent cough and evaluated for emer- inhaler), are given over a predefined time frame (2–4
gence of any specific cough pointers. (9) weeks), and have concrete therapy end points. (9)(11) If
If cough persists at follow-up, clinicians can discuss the an empirical trial of therapy is pursued, the child should be
options with parents: 1) continued watchful waiting and reassessed in 2 to 4 weeks. If the cough does not improve
reassessment in 2 weeks or 2) a trial of therapy. If the parents with a daily low-dose ICS in 2 to 4 weeks, the dose should not
opt for watchful waiting, children must be evaluated in the be increased, and the medication should be stopped. At
subsequent 2 weeks for resolution of cough, and a trial of follow-up, if cough resolved with an empirical trial of
therapy should be considered if cough persists. At this point, asthma therapies, this can suggest underlying asthma or
it is important to distinguish between nonspecific dry cough spontaneous resolution of cough (the period effect). Hence,
and wet cough. to confirm the diagnosis, a trial off the medication should
For nonspecific dry cough, asthma can be a cause, be performed. If cough recurs, the asthma therapies should
particularly if the child has other atopic features (eczema, be resumed. At each follow-up visit, the clinician should
allergic rhinitis) and a family history of asthma. Some review specific cough pointers, as well as evaluate tobacco
children with asthma can have cough as the predominant smoke exposure, other pollutant exposure, parental expec-
symptom. (7) However, unless wheezing and dyspnea are tations, and evidence of any underlying illness. When the
also present, few children with isolated nonspecific cough clinical diagnosis of asthma in young children is
Summary
• Acute cough in children is usually caused by viral upper
respiratory tract infections, which are self-limiting. There is no
good evidence of effectiveness of over-the-counter cough
medicines in acute cough, and they can cause serious harm in
children. (13) References for this article are at http://pedsinreview.aappubli-
cations.org/content/40/4/157.
1. A 10-year-old girl with a medical history of asthma presents to the office for evaluation of a REQUIREMENTS: Learners
5-week history of daily dry cough. She reports occasional bouts of shortness of breath, can take Pediatrics in Review
which improve with the use of her bronchodilator inhaler. She denies fever, nasal quizzes and claim credit
congestion, or chest pain. Which of the following factors support the classification of her online only at: http://
cough as chronic? pedsinreview.org.
A. Absence of fever and nasal congestion. To successfully complete
B. Characterization of cough. 2019 Pediatrics in Review
C. Clinical response to the use of a short-acting b2 agonist. articles for AMA PRA
D. Presence of daily cough for greater than 4 weeks. Category 1 CreditTM, learners
E. Previous diagnosis of asthma. must demonstrate a minimum
2. Children and adolescents with chronic cough with characteristics suggestive of specific performance level of 60% or
underlying etiologies should be evaluated promptly and may benefit from a consultation higher on this assessment.
with a pediatric pulmonologist. Which of the following clinical scenarios involving chronic If you score less than 60%
wet cough would be most appropriate for a pediatric pulmonology referral? on the assessment, you
A. Allergic rhinitis with postnasal drip. will be given additional
B. Congenital heart disease with airway casts. opportunities to answer
C. Gastroesophageal reflux disease with weight loss. questions until an overall 60%
D. Moderate persistent asthma controlled with inhaled corticosteroids. or greater score is achieved.
E. Tic disorder with vocal tics including habit cough. This journal-based CME
3. A 9-year-old girl presents for an initial visit to establish care in your practice after recently activity is available through
moving to the United States. The mother states that she has always suffered from frequent Dec. 31, 2021, however, credit
respiratory infections, for which she has been prescribed multiple courses of antibiotics. will be recorded in the year in
She reports having wet cough with sputum production daily and shortness of breath with which the learner completes
physical activity weekly. The mom is also concerned with her slow rate of growth and the quiz.
weight loss of 8 lb over the past year. On physical examination she is below the 5th
percentile in both height and weight for her age. You note coarse crackles through the
bilateral lung fields and mild digital clubbing. Based on the cough pointers in the history
and findings on physical examination, which of the following is the most likely underlying
diagnosis of this patient’s chronic cough?
A. Cystic fibrosis. 2019 Pediatrics in Review now
B. Pertussis infection. is approved for a total of 30
C. Retained foreign body. Maintenance of Certification
D. Tracheoesophageal fistula. (MOC) Part 2 credits by the
E. Tuberculosis infection. American Board of Pediatrics
through the AAP MOC
4. A 5-year-old previously healthy boy is brought to the pediatrician’s office for evaluation of
Portfolio Program. Complete
prolonged cough. The mother reports that the boy’s illness began 4 weeks ago with fever
the first 10 issues or a total of
of 3 days’ duration, nasal congestion, and cough. The mother is concerned because the
30 quizzes of journal CME
cough has persisted despite resolution of fever and improvement of other symptoms. The
credits, achieve a 60% passing
cough is described as dry and presents both during the day and at night. On physical
score on each, and start
examination the boy is well-appearing and in no distress. Chest auscultation reveals good
claiming MOC credits as early
air entry bilaterally and no wheezing or crackles. Findings on the chest radiograph are
as October 2019. To learn how
within normal limits. Which of the following is the best next step in management?
to claim MOC points, go to:
A. Initiate a trial of a short-acting inhaled b2 agonist and inhaled corticosteroid. http://www.aappublications.
B. Order pulmonary function tests. org/content/moc-credit.
C. Prescribe a 2-week course of amoxicillin-clavulanate.
D. Recommend supportive care and reassess the patient in 2 weeks.
E. Refer to a pulmonologist for flexible bronchoscopy.