|Year : 2019 | Volume
| Issue : 2 | Page : 87-92
Santosh Kumar Swain1, Sampada Munjal1, Suryakanta Pradhan2
1 Department of Otorhinolaryngology, IMS and SUM Hospital, Siksha ‘O’ Anusandhan University (Deemed to be), Bhubaneswar, Odisha, India
2 Department of Otorhinolaryngology, Apollo Hospital, Bhubaneswar, Odisha, India
|Date of Submission||22-Jan-2019|
|Date of Acceptance||29-Apr-2019|
|Date of Web Publication||19-Jun-2019|
Santosh Kumar Swain
Department of Otorhinolaryngology, IMS and SUM Hospital, Siksha ‘O’ Anusandhan University (Deemed to be), Bhubaneswar, Odisha
Source of Support: None, Conflict of Interest: None
Cough in the pediatric age group is a common presenting complaint, and the etiology of the cough is often elusive. Although there is a high prevalence of cough in the pediatric age group, the subject is still poorly researched. The management of pediatric cough is different from adults. Cough in children causes a significant anxiety among parents and often leads to the use of inappropriate or unnecessary medications. Cough in the pediatric population is due to multiple underlying causes and the most common are allergy, infections, asthma, foreign body aspiration, and gastroesophageal reflux. Detailed history-taking and physical examination with chest X-ray and spirometry are often recommended for getting the diagnosis. Treatment is done according to the underlying disease, and there is poor evidence for prescribing medications only for symptomatic relief. This review article discusses the etiopathology and clinical characteristics of pediatric cough and its management.
Keywords: Airway, asthma, cough, pediatric patient
|How to cite this article:|
Swain SK, Munjal S, Pradhan S. Pediatric Cough. Apollo Med 2019;16:87-92
| Introduction|| |
Cough is a common presenting symptom in clinical practice, whereas a persistent cough is one of the most common clinical problems for which the patient referred to pediatrician, pulmonary physicians, and otolaryngologists.
Cough is a physiological reflex present with violent expiration to remove the secretions and foreign bodies, overcome bronchospasm, and protect the respiratory system. The receptors for the cough are seen along the airway from the larynx to segmentary bronchi and stimulated by chemical irritation, mechanical stimulation, and tactile stimulation. The cough reflex has afferent pathway through branches of the vagus nerve and laryngeal nerves to the brainstem and the impulse modulated at the cerebral cortex followed by the efferent motor pathway goes to respiratory muscles. Upper respiratory tract infections (URTIs), bronchial asthma, gastroesophageal refl ux disease, bronchial hyperactivity and angiotensin-converting enzyme (ACE) inhibitor treatment cause increase sensitivity of the cough receptors. Cough is one of the most common clinical presentations among children, for which they come to general practitioners or clinicians for the treatment and often referred to pediatricians. Cough in children affects daily activities and often disturbs the child's sleep as well as the parents. Cough is not only a symptom of a disease but also a physiological defense symptom. It can be acute (<3 weeks), prolonged acute (3–8 weeks), or chronic (>8 weeks duration). Depending on the content of the cough, it is divided into productive where secretions arise from the respiratory tract and dry cough without any secretions.
| Method of Literature Search|| |
Articles regarding pediatric cough were searched through a multistage systematic approach. Initially, we conducted an online search of Scopus, Medline, and PubMed database with the word pediatric cough and/or cough in children. Then, we systematically analyzed and reviewed all the literatures. There are limited studies on pediatric cough in comparison to adult one.
| Epidemiology|| |
Cough is a common cause for which patient need medical consultation. There are very little population-based data for cough in the pediatric age. The prevalence of cough in the pediatric age group varies with age, sex, and questions asked for assessing the cough. In the community, the prevalence of cough is 9%–33% and economic burden to the society is substantial. Pediatric cough is a common clinical presentation in a primary health-care center. Approximately 35% of preschool children present cough and around 9% of 7–11-year-old children present cough.
| Etiopathology|| |
Cough is a defensive mechanism which protects the airway from aspiration and clears the secretion from the airway. It is usually described as an inspiratory effort followed by forced expiration against the closed glottis and results in a rapid expulsion of the air. A cough reflex is observed among patients of neuromuscular disorders and stroke which lead to increased chance of aspiration and pulmonary infection, whereas a heightened cough reflex is typically seen in chronic cough patients. The cough reflex is based on sensory nerve fibers carried by vagus which are responsive to the mechanical and chemical stimuli. These nerve fibers are integrated into brainstem circuit which is responsible to create cough through phrenic, intercostal, laryngeal, and abdominal motor neuron pathway to muscles associated with cough. The detail etiologies of pediatric cough [Table 1] are discussed.
This is a very common cause for cough among children. Cough occurs due to the inflammatory process of tracheobronchial tree. It is secondary to viral infections from rhinovirus, coronavirus, adenovirus, influenza A and B, parainfluenza, or respiratory syncytial virus. Children in virus-induced cough often presents with associated symptoms such as running nose, blocked nose, and cough. It lasts for 3–4 weeks. The term acute bronchitis is often used to describe a cough for viral-induced inflammation of tracheobronchial tree.
Laryngopharyngeal reflux (LPR) is manifested by extraesophageal reflux disease. There is direct contact of the larynx with low-pH irritant stomach contents. On examination with laryngeal endoscopy, the findings are often variable and include posterior commissure hypertrophy, granuloma, subglottic edema, ventricular obliteration, vocal cord edema, erythema, hyperemia, and thick endolaryngeal mucus. In LPR, troublesome cough is often only symptom and patients sometimes consult pulmonary medicine specialists and undergone pulmonary investigations for some time before confirmation of LPR disease. Other symptoms in LPR are variable and include sore throat, throat clearing, and hoarseness of voice.
Approximately 9.1% of the pediatric population <18 years of age have been diagnosed with asthma. Asthma is aggravated by exposure to environmental allergens (molds, animal dander, pollens, and dust mites), air pollution, exercise, and cold temperature. Viral infections such as respiratory viruses are an important trigger for wheezing in infants and childhood asthma. The airway in asthmatic child is microscopically identified by an infiltrate of eosinophils and Th2 lymphocytes which express interleukins (IL)-4, IL-5, and IL-13. Allergy plays a major role for causing asthma among children. Bronchial asthma is characterized by a variable course of cough, dyspnea, wheezing, bronchial hyperresponsiveness, and reversible airflow limitation. Wheeze may be found during clinical assessment, but not in all the time. Persistent nocturnal cough is an important symptom, although often it is reported without the presence of wheeze.
Foreign body aspiration
Foreign body aspiration is commonly seen in children below 3 years of age. The diagnosis of foreign body should be suspected when there is sudden chocking followed by prolonged cough along with nonresponding pneumonia. When clinical presentations are delayed and with doubtful history; physical examination and imaging are helpful for the confirmation of foreign body aspiration. Common clinical presentations are chronic cough, recurrent pneumonia, and localized area of bronchiectasis. The immediate treatment is bronchoscopic removal of foreign body when there is clinical or parental suspicion. Reflux or aspiration of gastric contents or food is an important cause for pediatric cough in clinical practice. Patients often present with cough and wheeze. Microaspiration and vagal reflexes at the esophagus may lead to respiratory symptoms.
Children with rhinosinusitis often present with nasal secretions with or without a wet or dry occurring. It is more among children with atopy and is considered if clinical symptoms persist >4–8 weeks. Facial pain and discomfort are not much common in comparison to adults. Antibiotics and anti-allergic treatment are often helpful for treating rhinosinusitis in children. In few studies, amoxicillin–clavulanate showed a considerable benefit in pediatric rhinosinusitis with cough.,
Congenital ciliary abnormalities impair the mucociliary clearance of the respiratory airway and lead to respiratory symptom like cough. The diagnosis of primary ciliary dyskinesia is suspected in pediatric patients when associated with severe nose, ear, and throat infections and lower respiratory airway infections. Sometimes, primary ciliary dyskinesia is associated with situs inversus.
Tracheo- and/or bronchomalacia
Pediatric patients with tracheo- and/or bronchomalacia often present with wheezing, stridor, recurrent barking cough, or frequent infections of the respiratory airway. The severity of the symptoms depends on the degree of collapse. Conventional chest X-ray is not much helpful and needs bronchoscopy preferably flexible bronchoscopy under spontaneous ventilation for the diagnosis. Before diagnosis, children often misdiagnosed for reactive airway disease.
Acute laryngotracheobronchitis (croup)
It affects young children between 6 months and 3 years of age. It is caused by viral infection of the respiratory tract and causing edema and inflammation of the upper airway with narrowing of the subglottic airway. Human parainfluenza virus (Type-1 and 3) is the most common pathogen for croup. Here, the child presents with rhinorrhea, fever, barking cough, hoarse voice, and inspiratory stridor during the night.
Congenital abnormalities of the airway may be the cause of chronic cough in children. Tracheoesophageal fistula (TOF) or laryngeal cleft causes cough by aspiration, particularly during taking food. Congenital tracheobronchomalacia causes cough after birth. Airway compression, airway stenosis, coarctation of the aorta can cause chronic respiratory symptoms. In these case children may present with seal like barking cough and it will be more severe when associated respiratory tract infections. Tracheal causes like compressive lesions such as vascular rings, hemangioma, cysts and masses in the mediastinum are important etiology for cough. Children those operated for TOF or esophageal atresia usually present with tracheomalacia and disabling cough, called as “TOF” cough. With progress of the time, the cartilages of the trachea strengthen and cough subsides.
Exposure to smoke, other contaminants of environment, and smoking by children and adolescents are also important causes for cough among children.
Common aggravating factors for cough in children are rhinitis, tonsillar enlargement, ear wax (Arnold's reflex), gastroesophageal reflex, snoring, ACE-inhibitor drug therapy, premature ventricular complexes, and obstructive sleep apnea.
| Characteristic of Pediatric Cough|| |
Loud or brassy cough is often associated with tracheomalacia and very specifically seen when associated with a TOF cough. Whooping cough or pertussis is characterized by severe paroxysms of coughing followed by a gasping inspiration leading to characteristic whoop. This characteristic whoop of the pertussis may not be found in very young infants, older children, or adolescents., Psychogenic cough is presented as dry repetitive habit “tic-like” coughs or bizarre type and honking with the children and not being disturbed with cough. Both types of coughs are often disappeared when the child is engrossed in an activity or asleep. Cough is classified into acute, subacute, and chronic. Cough is called acute when the duration is <2–4 weeks. In most of the cases, the cause of acute cough is URTI. The URTI is mostly viral infections and sometimes bacterial. Subacute cough lies in between acute and chronic cough where the duration falls between 4 and 8 weeks. It is often caused by prolonged URTIs or bacterial infections. As per the recommendation, if cough persisting >4 weeks, a chest X-ray is advised. If chest X-ray is normal, the child should be monitored for 6–8 weeks and still if cough is not relieved, considered as chronic where appropriate diagnostic and therapeutic measures are started. The chronic cough persists for >4–8 weeks.
Complications of cough
Cough may have different complications in addition to the beneficial effects such as airway clearing. Forceful cough may lead to bronchospasm, rib fracture, pneumomediastinum, or syncope. Sometimes, forceful cough may be associated with pulled rectus abdominis muscle or intercostal muscle. Although anxiety is a known risk factor among adult patients suffering with chronic cough, there is no such study among pediatric patients. In older child, cough often causes psychological influences.
| Diagnosis|| |
A careful history-taking is often helpful for identifying the cause and aggravating factors for cough. The clinical symptoms such as irritation in the throat, habit of smoking either passive or active, medication history such as ACE inhibitor use, and aggravating factors such as gastroesophageal reflux and rhinitis are important part during consideration of diagnosis. Cough along with hemoptysis, weight loss, and fever needs prompt evaluation and rule out infection and malignancy. Pediatric patients presenting with acute cough usually do not need investigations as the progress cough is often self-limiting. Clinical examination, chest X-ray, and spirometry are helpful to identify a wide range of bronchopulmonary disorders. A chest X-ray is usually advised if there is suspicion of chronic respiratory diseases or pneumonia, hemoptysis, sudden cough, or sudden choking which might suggest foreign body aspiration. In this clinical situation, inspiration and expiration chest X-ray should be taken. Characteristic cough often helps get diagnosis. Cough associated with wheezing suggests that asthma, metallic cough, or hacking may be associated with laryngomalacia, tracheomalacia, or croup. A paroxysmal cough with the presence or absence of stridor may suggest pertussoid syndrome. A staccato cough may be seen in Chlamydia trachomatis or Mycoplasma pneumonia infection. Croaking and strident cough may be associated with psychogenic cause. Fiber-optic bronchoscopy should be done in all pediatric patients with chronic cough and suspicion of foreign body aspiration, airway abnormalities, localized radiological abnormality in the airway, and performing bronchoalveolar lavage and microbiological studies., Pulmonary function test/spirometry can be performed from the age of 3–4 years with appropriate training. A positive bronchodilator test suggests asthma. Fiber-optic bronchoscopy should be required in case of pediatric chronic cough with suspecting the foreign body inhalation or any airway abnormality. If there is any evidence of radiological changes, bronchoalveolar lavage and microbiological studies can be performed. The diagnosis of foreign body aspiration suspected if there is a history of choking followed by sudden onset of cough and nonresolving pneumonia. The yield from clinical examination and imaging for the diagnosis of foreign body aspiration is relatively low, but it is more when the presentation is delayed. The sensitivity and specificity of each diagnostic criteria in case of foreign body aspiration are as follows: symptoms (sensitivity – 68% and specificity – 53%); clinical history (sensitivity – 63% and specificity – 32%); physical examination (sensitivity – 70.5% and specificity – 63%); radiological/imaging findings (sensitivity – 73% and specificity – 68%); and the triad of cough, wheeze, and decreased breath sound (sensitivity – 88% and specificity – 51%). Delayed diagnosis of foreign body aspiration is often due to unobserved aspiration event or lack of clinician awareness and serious consequences such as recurrent pneumonia, chronic cough, and eventually focal area of bronchiectasis. Pediatric patients with chronic cough often require chest X-ray to confirm the diagnosis. Monitoring pH is usually performed in case of suspecting gastroesophageal reflux disease (GERD). As normal pH report does not exclude the presence of acid reflux, so it must be evaluated further by impedance tests for confirmation.
| Treatment|| |
Cough among pediatric patient is a common reason for seeking medical attention. Cough is a distressing symptom which requires significant health-care costs by medical consultations. Nonspecific treatment such as prescribing cough-suppressant therapy provides little benefit in managing the coughing child. Successful treatment is based on the accurate diagnosis and understanding the exact etiology of cough. There is little evidence for prescribing medications for symptomatic relief of pediatric cough. If symptomatic treatment is done, it is imperative that the pediatric patients should be routinely followed up and treatment should be stopped if there is no outcome within the expected time period. The etiology of the pediatric cough varies from viral URTI to some unexplained causes despite through investigation. Cough reflex hypersensitivity is an important abnormality seen in cough, and the term cough hypersensitivity syndrome (CHS) has recently been used to emphasize this. The treatments of CHS include identifying the reversible cough hypersensitivity, reducing aggravating factors, and treating with nonspecific antitussive treatment. Twenty percent of pediatric cough have associated with adenoid hypertrophy and they need adenoidectomy. In theses cases, adenoidectomy reduces postnasal drip, improves nasal airflow, and improves chronic cough or croup like symptoms. Chronic cough due to bronchial asthma needs treatment with bronchodilators and inhaled corticosteroids. Leukotriene inhibitors, cromolyn, and long-acting beta-2 agonists should be added in the treatment. In case of allergic rhinitis with cough, pediatric patients need antihistamines and intranasal steroids. Sinusitis usually requires antibiotics, steam inhalation, and saline nasal drops. GERD with cough should be managed with proton-pump inhibitors and/or surgery. Chronic bacterial bronchitis needs long-term treatment of amoxicillin–clavulanate or clarithromycin for the duration of 2–6 weeks. In children, antibiotic has no role in reducing cough due to viral-induced upper respiratory infections. In case of chronic psychogenic cough, the investigations are needed to find out the causes for stress or anxiety and subsequent psychological support. Viral-induced cough is usually treated by ensuring adequate fluids, rest, and paracetamol if needed. In case of children presenting with chronic, nonspecific cough, rather than prescribing multiple medications and risk of undesired side effects, a wait-and-watch approach is prudent, where a period of time elapses without any medications and the pediatric patients are reevaluated. In children with foreign body aspiration, the immediate management is endoscopic removal of foreign body from the airway and it should be done when there is clinical or parental suspicion. Croup or acute laryngotracheobronchitis is an acute viral infection of the airway in young children. Children with croup are treated with corticosteroids and those presenting respiratory distress are given with epinephrine nebulization and oxygenation. One study revealed that honey is better than “no treatment” for relief of the pediatric cough and improves the quality of sleep for both children and parents. It is a good home remedy for reducing cough among children.
In the management of pediatric cough, irrespective of etiology, attentions should be given to exacerbation factors leading to cough. Cessation of parental smoking is an important part in the management of pediatric cough. Counseling and cessation of smoking among smokers help reduce the children's cough.
| Conclusion|| |
Cough in the pediatric age group is a common and distressing symptom which leads to significant health-care costs by medical consultations and use of medication. Pediatric cough often presents a diagnostic and treatment dilemma. The patients often treated by pulmonologists, pediatric otolaryngologists, or gastroenterologists. The treatment of cough in children should be based on the etiology. There is no evidence of using medications for symptomatic relief of cough. Cough in children should be treated differently in comparison to adults as the etiological factors for the pediatric age group are different than adults.
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