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Management of Pediatric Cough

NOVEMBER 12, 2015

Patient Case
A 5-year-old girl presents to your clinic for a sick

Chief complaint: cough for 7 days
Started with 4 days of URI symptoms and cough

URI symptoms have resolved
Cough persists

Cough is present day and night

Worse at night
Keeping parents and child up at night
Disrupting her teachers and classmates

Discuss the epidemiology of pediatric cough
2. Review the physiology/pathophysiology of cough
3. Introduce algorithms for diagnosis of cough
4. Discuss safe, effective treatment options for cough

Pediatric Cough
Occurs in more than 2/3 children with the common cold

And most children have 6-8 colds per year!

It is disturbing to families, classmates, teachers
Interrupts sleep, school performance, ability to play

Disrupts sleep for 88% of children and 72% of parents (De Blasio

Generates parental anxiety
Annually, leads to:

22 million missed days of school
20 million absences from work

Types of Cough
Acute: < 3 weeks
Subacute: 3-8 weeks
Chronic: > 8 weeks (some say > 4 or > 6 weeks)
Recurrent: >2/year cough episodes, each lasting more

than 7-14 days
Postviral cough: Originally starts with URI, lasts > 3
Specific cough: clearly identifiable cause
Nonspecific cough: persistent dry cough without other
respiratory symptoms, no signs of CLD, normal CXR
Shields et al. Thorax 2008.

Cough reflex prevents the entry of harmful substances
Expels excess secretions and retained material in tracheobronchial tree
Begins with stimulation of cough receptors

Upper and lower airways
Ear canal, tympanic membranes, sinuses, nose, pericardium, pleura, and diaphragm

Afferent pathway: via vagal, phrenic, glossopharyngeal, or trigeminal


Signal to cough center (medulla)

Involuntary reflex + voluntary suppression or initiation

Therefore, higher centers are also involved in the afferent limb

Efferent pathway: From medulla to larynx, tracheobronchial tree, and

expiratory muscles

Act of Coughing
2. Expiration against closed glottis (compressive phase)


Buildup of intrathoracic pressures (50 to 300 cm H2O)
Pressures may be transmitted to vascular, cerebrospinal, and
intraocular spaces

3. Glottis opens, allowing for explosive expiratory air flow

(300 m/second)
4. Expulsion of mucus
.Inhibited by:
. Tracheostomy

(inability to seal upper airway)
. Muscular dystrophy (weak ventilatory muscles)

Initial Work-Up: Focused History
Age of the child
Nature of cough
Stridor or wheezing
Timing and season
Sputum, presence and character
Exposure to infection
Response to previous therapy
Family history of asthma/atopy/eczema/CF

Key questions
Choking in past 3 months?
Stool pattern
Past surgeries?
Sick contacts (pertussis!)

Using an Algorithm to Diagnose Cough
Chang et al (2013): Multicenter, randomized

controlled trial

Children with cough > 4 weeks
Following a standard algorithm improves cough and identifies
85% of diagnoses
Final diagnosis:

26% with nonspecific cough, 73.5% with specific cough
Nonspecific cough: Natural resolution (15%), Habit (5%), Pertussis
(3.5%), Mycoplasma (2.2%), Upper airway problems (1.3%)
Specific cough: Bacterial bronchitis (42%), asthma (16.4%),
bronchiectasis (5.7%), aspiration (1.3%), tracheobronchomalacia
(7.1%), atelectasis (0.9%), cystic fibrosis (0.4%).

Diagnostic Framework using Age and Duration



Chronic (>4 weeks)


Infection, Aspiration,
Foreign body

Reactive airways, CF,
GER, aspiration,
anatomic, passive

Reactive airways, CF,
GER, aspiration,
pertussis, anatomic,
passive smoking,


Infection, foreign
body, aspiration

Reactive airways, CF,
GER, aspiration,
anatomic, passive

Reactive airways, CF,
GER, aspiration,
pertussis, anatomic,
passive smoking


Infection, foreign body

Reactive airways, CF,
GER, passive smoking

Reactive airways, CF,
GER, pertussis,
anatomic, passive



Reactive airways, CF,
GER, aspiration,

Reactive airways, CF,
GER, smoking,
psychogenic, pertussis,
aspiration, anatomic

Symptom-Based Algorithm
for Differential Diagnosis

Foreign body, pulmonary embolism, inhaled Cough

Nasopharyngitis, sinusitis, laryngotracheitis

Viral, bacterial pneumonia; hypersensitivity



CF, asthma, tuberculosis, mediastinal disease,
CF, Immunodeficiency, leukocyte disorders, ciliary
dyskinesia, anatomic disorders, sickle cell

Sudden onset?

Fever, rhinorrhea, normal chest exam?

Fever, abnormal chest exam, acute onset?

Chronic cough?

Recurrent cough and pneumonia

Clinical Pearls to Aid in Diagnosis

Clinial finding

Clinical Clues

Think of…

Staccato, paroxysmal

Pertussis, CF, foreign body, Chlamydia, Mycoplasma



All day, never during sleep


Barking, brassy

Croup, psychogenic, tracheomalacia, tracheitis, epiglottitis


Laryngeal involvement (croup, recurrent laryngeal nerve)

Abrupt onset

Foreign body, pulmonary embolism

Follows exercise

Reactive airway disease

Accompanies eating/drinking Aspiration, GER, TEF
Throat clearing

Postnasal drip

Productive (sputum)


Night cough

Sinusitis, reactive airway disease


Allergic rhinitis, reactive airway disease


Bacterial PNA, Pneumocystis, TB, MAC, CMV


Hypoxia, hypercarbia

Animal exposure

Chlamydia psittaci, Yersinia pestis, Tularemia, Q fever,
hantavirus, histo


Histo, coccidiodomycosis, blasto

Workdays only


Patient Case, continued
T 36.8, P 110, R 20, BP 94/65, Sat 99%; weight & length

at 45th percentile
HEENT: TMs clear, nares with clear mucus, moist
mucous membranes, oropharynx clear without tonsillar
hypertrophy or exudates
CV: RRR, normal S1/S2, no m/r/g, +2 pulses
Resp: No tachypnea or retractions, CTAB. Cough is dry,
no hoarseness to voice.
Abd: Soft, NT/ND, no HSM or masses
Ext: no edema, no clubbing, no deformities
Skin: no rashes, no bruising, no cyanosis
Neuro: grossly intact

Red Flags- Not Just a Cold?
Persistent fever, high fever (>39)
Ill appearance
Absence of nasal symptoms
Wheezing, dyspnea, hypoxemia
Focal findings on lung examination

dullness to percussion, reduced air entry, crackles, bronchial breathing

Acute onset/choking
Features of chronic respiratory disorder

Failure to thrive, steatorrhea, finger clubbing, over-inflated chest, chest
deformity, atopy

Cough > 6 weeks

Treatment for Cough

Treatment of Cough
Supportive care!

Maintain adequate hydration

Ingestion of warm fluids

Thins secretions, soothes respiratory mucosa
Soothes respiratory mucosa, may loosen secretions

Suction bulb for infants
Encourage rest

Frequently Recommended Treatments
Humidified air (cool mist)?

Systematic review 2013: inconsistent benefit on symptoms of common cold
Not recommended by WHO (hypersensitivity pneumonitis
Remind parents to clean after each use to minimize risk of infection or
inhalational injury

Honey in > 1 year old patients

Modest effect on nocturnal cough (Randomized trial, n=300: improvement
in cough frequency, severity, and “bothersomeness” compared to placebo)
Antioxidant properties, increase cytokine release

Agave nectar

Compared to placebo, no additional benefits in infants/toddlers (Paul 2014)


No evidence that it helps
Probably not harmful

What About OTC Meds?
Caregivers frequently administer

Lack of proven efficacy
Disapproval of AAP and FDA
Dart et al: 118 fatalities in children younger than 12 related to cough/cold

103 cases involved non-prescription medication; 88 involved an overdose
Pseudoephedrine (n=45), diphenhydramine (n=38), dextromethorphan (n=36)
Contributing factors: age < 2 years, use of medication for sedation, use in daycare
settings, use of 2 meds with the same ingredient, failure to use measuring device,
product misidentification, use of nonprescription product intended for adult use

General consensus:

Do not use in children < 6 years (or even older children)
If you’re going to use them- use single-ingredient medications to avoid
potential toxicity
Paul. Pediatrics. 2004
Schroeder. Arch Dis Child 2002.

Not effective for cough in nonasthmatic children

Aromatic Vapors
Menthol, camphor, eucalyptus oil

Unsafe for children < 2
Only use on head/neck in children < 6

Randomized trial of 138 children (but not well


Compared with petroleum and no treatment, vapor rub was more
effective than petroleum and no treatment, but 50% had mild

Side effects

Swallowing a few teaspoons of camphor can cause fatal poisoning
Topical camphor absorbed through broken skin may lead to

Don’t put in/around nostrils!

Other remedies

Inhibits rhinovirus replication
Reduces symptom duration by 0.6 days in children
Benefits are modest and side effects common (bad taste, nausea, loss of


No better than placebo for URI
7% developed rash

Vitamin C

Did not reduce duration of illness short-term
Prophylaxis: shortens duration of common cold by 14.2%
No adverse effects

Vitamin D

No improvement in adults, no studies in kids


Patient case
Recommend supportive care
Nasal saline
Consider humidifier
Follow up in 2 weeks if cough persists, or sooner if

cough worsens

Berter H, Jarosch E, Madreiter H. Effect of vaporub and petroleum on frequency and amplitude of breathing in children

with acute bronchitis. J Int Med Res 1978;6(6):483-6.
Chang AB, et al. A cough algorithm for chronic cough in children: A multicenter, randomized controlled study. Pediatrics
Cohen HA, et al. Effect of honey on nocturnal cough and sleep quality: A double-blind, randomized, placebo-controlled
study. Pediatrics 2012;130:3.
De Blasio, et al. An observational study on cough in children: epidemiology, impact on quality of sleep and treatment
outcome. Cough 2012;8(1):1.
Google Images
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Paul I, Yoders KE, Crowell KR, et al. Effect of dextromethorphan, diphenylhydramine, and placebo on nocturnal cough and
sleep quality for coughing children and their parents. Pediatrics 2004;114:e85-90.
Passali D, et al. A prospective open-label study to assess the efficacy and safety of a herbal medicine supplement (Sinupret)
in patients with acute rhinosinusitis. ORL J Otorhinolaryngol Relat Spec 2015;77(1):27-32.
Pfeiffer WF, A multicultural approach to the patient who has a common cold. Pediatr Rev 2005;26(5):170-5.
Schroeder K, Fahey T. Should we advise parents to administer over the counter cough medicines for acute cough?
Systematic review of randomized controlled trials. Arch Dis Child 2002;86:170-5.
Shadkam MN, et al. A comparison of the effect of honey, dextromethorphan, and diphenhydramine on nightly cough and
sleep quality in children and their parents. J Altern Complement Med 2010;16(7):787-93.
Shields MD, et al. Recommendations for the assessment and management of cough in children. Thorax 2008;63:iii1-iii15.
Smith SM, Schroeder K, Fahey T. Over-the-counter (OTC) medications for acute cough in children and adults in
ambulatory settings. Cochrane Database Syst Rev 2012;8(8):CD001831.
The common cold in children: Clinical features and diagnosis. Up to Date. Accessed 11/8/2015.