George Waterman
CLINICAL PRESENTATION
Cough is a frequent complaint for children who present to the emergency department (ED). Coughing is a vital reflex for clearing secretions from the airway and for protection from inhalation of foreign matter. Although in many cases cough is caused by a self-limited viral illness, it is a nonspecific symptom requiring a systematic approach to exclude serious pathology (1).
DIFFERENTIAL DIAGNOSIS
There are multiple possible etiologies for coughing in a child. Selected causes will be discussed in more detail. A more comprehensive list can be found in Table 231.1.
TABLE 231.1
Causes of Cough in Children (2)
The most common cause of childhood cough is viral upper respiratory infection (3). These children are typically well appearing and often exhibit rhinorrhea on examination. Coughing associated with these illnesses is expected to resolve within 3 weeks (4).
Upper airway cough syndrome is a common cause of cough due to irritation of the upper airway from postnasal drip due to viruses or allergens. This is a frequent cause of acute cough in children with common colds (5).
Asthma may sometimes present with coughing as the predominant symptom (6). Supportive evidence of a diagnosis of asthma includes a personal or family history of atopic symptoms such as eczema or allergic rhinitis (7).
Coughing has been cited as a common symptom in many cases of foreign body aspiration (8). A foreign body must be ruled out if a persistent cough follows a choking episode.
Cough associated with fever, tachypnea, and rales on auscultation is a concern for pneumonia. These children are often ill appearing with increased work of breathing. Streptococcus pneumoniae is the most common bacterial pathogen, but other likely possibilities include viruses, Mycoplasma pneumoniae, and Chlamydia pneumoniae (see Chapter 265) (9).
Bordetella pertussis should be considered if cough is prolonged (>3 weeks) in duration, if it is paroxysmal, and if associated with posttussive emesis (10). Despite widespread vaccination, the incidence of pertussis has been on the rise for the past 15 years (see Chapter 262) (11).
Chronic cough in infants and children is often caused by asthma or recurring viral upper respiratory infections. Anatomic abnormalities, such as anomalies causing compression of the airway, can lead to persistent or recurrent symptoms. These include vascular rings, coarctation of the aorta, hemangiomas, pulmonary sequestrations, and masses in the mediastinum. Tracheoesophageal fistula should also be suspected in infants with repeated episodes of aspiration or in those with features of VACTERL association (a group of abnormalities that may include Vertebral defects, Anal atresia, Cardiac defects, Tracheo-Esophageal fistula, Renal anomalies, and Limb abnormalities) (12).
Tuberculosis is a consideration in children who have a history of traveling to endemic areas, particularly if there are associated symptoms of weight loss, hemoptysis, and night sweats (13).
DIAGNOSTIC APPROACH
The examination of any patient with a cough will begin with evaluation of the airway and of the effectiveness of breathing and circulation. The airway should be evaluated for patency, and breathing for accessory muscle use and abnormal sounds. A complete set of vital signs including pulse oximetry should be obtained on arrival. If there is concern for increased work of breathing or hypoxemia, oxygen should be administered and the child should be kept in a position of comfort. Advanced airway equipment should be readily available for the child who does not respond to basic interventions. Children with severe croup or those with foreign bodies in the trachea may require intubation if they show signs of respiratory failure. Although rare in Western countries nowadays, if epiglottitis is suspected, intubation is ideally performed in the operating room. After initial stabilization as needed, a more detailed history and physical examination should be initiated. In the majority of cases, this will be sufficient to arrive at a diagnosis. Important historical elements are listed in Table 231.2.
TABLE 231.2
Historical Elements
The physical examination should begin with the overall appearance of the child while at rest. If possible, it may be useful to have a child sit in the caregiver’s lap initially to assess for work of breathing while the patient is calm. Important findings to note on physical examination are listed in Table 231.3.
TABLE 231.3
Physical Examination
A chest x-ray should be obtained if there is suspicion of a foreign body, significant respiratory distress, or concern for a bacterial etiology. If concern for foreign body persists despite nonvisualization on x-rays, bronchoscopy should be arranged. Other testing to consider in selected cases of cough include viral assays, sputum culture, pulmonary function testing, and swallowing studies.
Treatment for cough is targeted to the underlying cause. If the etiology is viral, there is no evidence that over-the-counter medications are useful and they may in fact have harmful side effects (14,15). Bronchodilators or racemic epinephrine may be used in conjunction with steroids if indicated for bronchospastic symptoms or croup. Antibiotics should be reserved for children with a likely bacterial source and follow-up should be arranged to ensure that symptoms are resolving as expected.
CRITICAL INTERVENTIONS
Evaluation of the ABC’s is the first priority in any patient with a cough, and is followed immediately by interventions needed for stabilization (e.g., nebulized medications, steroids). If signs of respiratory distress are present, cardiac and respiratory monitoring are indicated. Supplemental oxygen should be provided in patients who display increased work of breathing or hypoxia. If there is concern for aspiration of a nonradioopaque foreign body, bronchoscopy should be arranged.
DISPOSITION
Most children with cough may be discharged home if they do not have an oxygen requirement, are tolerating oral intake, and are not experiencing increased work of breathing. Other reasons to consider admission include the need for inpatient workup, outpatient antibiotic treatment failure, and concern for the parent’s ability to care for the child. It is important to stress to families that coughing associated with routine viral illnesses can last up to several weeks and that the utility of over-the-counter cough suppressants is modest at best and may be harmful.
Common Pitfalls
• Failing to optimize the conditions for physical examination. Auscultation for breath sounds should take place with the child in a position of comfort prior to uncomfortable aspects of the examination.
• A child with continued symptoms of foreign body aspiration should not be discharged even if the chest x-ray is negative.
• Failing to establish close follow-up in children with pneumonia and in those going home with bronchodilators.
• Prescribing empiric antibiotics when there is not a likely bacterial source and use of over-the-counter antitussives.
REFERENCES
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