Chronic Cough in Children

Aka: Chronic Cough in Children, Pediatric Chronic Cough, Chronic Cough Evaluation in Children

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II. Definitions: Children

  1. Chronic Cough
    1. Cough duration longer than 4 weeks

III. Causes: Common etiologies (ages 6 to 15 years old)

  1. See Chronic Cough Causes in Children
  2. Reactive airway disease or Bronchospastic condition
    1. Occurs in 70% of children at some time
    2. Worse at night and with Exercise
  3. Post-Viral inflammation (Post-Bronchitic cough)
    1. Persists 3 weeks after Upper Respiratory Infection
    2. Consider protracted Bacterial Bronchitis
  4. Upper Airway Cough Syndrome (UACS)
    1. Rare in children under 6 years old (consider other diagnosis)
    2. Allergic Rhinitis
      1. Eliminate environmental allergans and irritants
      2. Consider Allergy Testing
    3. Acute Sinusitis
      1. Rhinorrhea for 2 weeks is Sinusitis in 70-85% cases
      2. Eye mattering may be associated

IV. History

  1. Nature of cough
    1. Croupy cough
    2. Loose rattling cough
    3. Throat clearing (Hawking) suggests postnasal drip
    4. Dry brassy cough ("kak kak kak")
  2. Cough Timing
    1. Cough during sleep
      1. Post Nasal Discharge
      2. Bronchospasm
    2. Cough on awakening (Sputum productive)
      1. Consider Cystic Fibrosis
    3. Cough with Feeding
      1. Gastroesophageal Reflux disease
      2. Aspiration
      3. Discoordinated swallow
    4. Psychogenic cough disappears with sleep
    5. Seasonal cough
      1. Spring or fall: Allergic Rhinitis
      2. Winter: Bronchospasm from irritation
  3. Associated factors
    1. Exposures (e.g. Tobacco smoke)
  4. Underlying conditions
    1. Asthma
    2. Feeding difficulties
    3. Neurodevelopmental disorders
    4. Immunodeficiency

V. Exam

  1. General
    1. Evaluate pediatric height and weight curves
    2. Vital Signs
  2. Head and neck
    1. Evaluate for Acute Sinusitis
    2. Evaluate for Allergic Rhinitis
  3. Chest
    1. Anteroposterior Diameter
    2. Localized crackles
    3. Wheezes
    4. Resonance
    5. Decreased air entry or lag
    6. Tachypnea

VI. Findings: Red Flags for Serious Underlying Conditions

  1. Chest Pain
  2. Dyspnea
  3. Tachypnea
  4. Digital Clubbing
  5. Failure to Thrive
  6. Feeding difficulties
  7. Hemoptysis
  8. Recurrent Pneumonia

VII. Imaging

  1. Chest XRay
    1. Obtain in most cases of persistent cough without localizing symptoms (esp. age >3-6 years old)

VIII. Diagnostics

  1. Pulmonary Function Testing

IX. Labs: Consider

  1. Sputum exam
  2. Purified Protein Derivative (PPD)
  3. Sweat Chloride

X. Differential Diagnosis

  1. See Chronic Cough Causes in Children
  2. Most common causes
    1. Asthma or reactive airway disease
    2. Upper Airway Cough Syndrome
    3. Gastroesophageal Reflux
    4. Protracted Bacterial Bronchitis
      1. Di Filippo (2018) Ann Thoracic Med 13(1): 7-13 [PubMed]
    5. Bronchiectasis
  3. Serious chronic conditions (see red flag findings above)
    1. Aspiration lung disease
    2. Interstitial Lung Disease
    3. Cardiac conditions
    4. Airway abnormalities

XI. Management: First stage

  1. Upper airway (e.g. congestion, Rhinorrhea, post-nasal drainage)
    1. Consider empiric Antibiotic treatment for Sinusitis or protracted Bacterial Bronchitis (prolonged wet cough)
      1. Amoxicillin/clavulanate for 2 weeks
      2. Azithromycin
      3. Marchant (2018) Cochrane Database Syst Rev 7(7):CD004822 +PMID: 30062732 [PubMed]
    2. Consider trial of Antihistamine (with or without a Decongestant)
    3. Use inhaled Intranasal Corticosteroids if practical
    4. Environmental control in child's bedroom
      1. See Environmental Allergen
  2. Lower airway (reversible airway obstruction with Wheezing; Asthma or reactive airway disease)
    1. Consider trial of Inhaled Bronchodilators
    2. Consider trial of Inhaled Corticosteroids
    3. Prednisone short course occasionally may be helpful

XII. Management: Next Stage (If failure of first stage)

  1. Re-evaluation
    1. Cystic Fibrosis
    2. Asthma
    3. Gastroesophageal Reflux
    4. Congenital Anomaly
    5. Foreign Body Aspiration
    6. Immune disorder
  2. Intensify Asthma therapy
  3. Do not suppress the cough

XIII. References

  1. Michaudet (2017) Am Fam Physician 96(9): 575-80 [PubMed]
  2. Sonoda (2024) Am Fam Physician 110(2): 167-73 [PubMed]

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