Acute cough in children

Because acute cough has a different range of causes in children younger than 15 years of age than it does in adults, children should be assessed and treated differently. An important aspect of treating children is paying attention to parental concerns and expectations. 

Cough is the most common pediatric problem managed by FPs, and it is more common in preschool children than in older children. Two out of 3 children aged between 0 and 4 years visit their FPs at least once a year with acute respiratory infections, and up to three-quarters of them will have coughs. Most coughs are caused by acute viral infections, and 7% to 12% of coughs are due to asthma; all other causes are rare. With the exception of 0.3% due to whooping cough, all other coughs were the result of acute viral infections. Most coughs in children are caused by undifferentiated acute respiratory tract infections—a cough that does not conform to any clear diagnostic syndrome such as croup, whooping cough, pneumonia, or bronchiolitis. 
As with adults, children’s cough, whether described as a symptom of “upper respiratory tract infection” or “acute bronchitis,” is the most frequently managed acute presentation in primary care. These 2 diagnoses represent at least 75% of all coughs seen. Of the other causes, asthma is the most common; other, potentially dangerous, causes are much less common. 
What else could it be?
Acute cough in children are due to acute viral infections (common colds, acute bronchitis, croup, and influenza). Pediatricians should not miss conditions such as asthma, bronchiolitis, whooping cough, pneumonia, and foreign body aspiration. A brief focused history will usually give information about such conditions. 
What are the alarming symptoms?
If there were an epidemic at the day-care centre, one would have been informed. Immunization record will influence the chances of whooping cough or Haemophilus influenzae infection. A sudden history of choking will point to aspiration of a foreign body or exposure to toxic irritants. What time of year is it? Peak incidence of infective cough is January to March; epidemics of croup tend to occur in autumn and bronchiolitis in winter. 
What are the alarming signs?
The child will look ill (with pneumonia or influenza) or be short of breath with increased respiratory rate (with asthma or foreign body aspiration). The child will be working hard to breathe, perhaps with chest retractions. There might be a high fever (with pneumonia, but some children can run sudden high fevers with otherwise innocuous viral infections). 
How can we be sure of the diagnosis?
Most childhood respiratory tract infections are diagnosed based on history and examination alone. This is true for croup, which is associated with the same micro-organisms as the common cold. The barking cough of croup and the paroxysms of whooping cough are classic and easy to recognize, as is the wheeze in infants with bronchiolitis. Knowledge of the child’s vaccination status can help; clearly whooping cough and influenza are less common in children who have been immunized against these illnesses. 
Both doctors and parents worry that a coughing child might have pneumonia. Several studies have developed ways to rule out pneumonia: in the absence of tachypnea and chest retractions, if the respiratory rate is normal, auscultation is clear, and the child is not working hard to breathe, findings from chest radiographs are unlikely to be positive for pneumonia. 
Is it likely to get worse?
Up to 12% of children with cough experience complications, and although the complications are usually mild and easily treated, some children do become very sick. Otitis media is the most common complication, followed by rash, diarrhea, and vomiting; only 5% of cases progress to bronchitis or pneumonia. Unfortunately, there is a paucity of information regarding the predictive value of signs and symptoms in children with cough. 
Croup is a self-limiting illness. Only about 4% of children with croup need to be hospitalized, and only 1 in 4500 children with croup gets ill enough to require intubation. 
How long will the cough last?
Most children with croup are only mildly ill, and their croupy symptoms resolve within 48 hours. The cough might persist, however. Both clinicians and parents tend to underestimate how long acute cough in children will take to completely resolve. Prospective studies have found that not until 10 days after onset have 50% of children with coughs recovered, and 10% of children are still coughing at 25 days. 
What does the parent expect?
Mothers who consult their doctor because their children had been coughing found that one of the main concerns mothers have are that their children were going to die because of choking on phlegm or vomit; they were also worry about asthma and crib death. Some mothers also worry that their children will develop long-term chest damage. Mothers themselves are affected by sleep deprivation because of their worries about their children. 
What is the best treatment?
Evidence-based guidelines have shown that there are no effective medications to either cure or relieve the symptoms of acute cough in children. Once the pediatrician has confidently excluded the rarer and more serious conditions for which therapy is effective, explanation is required for the parent. 
Antibiotics have no effect on viral infections; indeed they might cause side effects that are more distressing than the cough. Most parents will not be too concerned about increasing antibiotic resistance; however, most should be told that antibiotics are at least as likely to cause side effects as they are to produce improvement in their children. They should also be told that serious adverse events and accidental poisonings have been recorded in children from exposures to over-the-counter medications.
There is good evidence that oral corticosteroids are an effective treatment for moderate to severe croup; they reduce symptom severity, illness duration, and return visits to the doctor. 
When should I bring my child back?
There is little need for most children with acute cough to be seen more than once. However, pediatricians know that some parents will need to be seen for further reassurance. Most parents will need to be told to return if the cough does not improve in a certain time (which is longer than most parents think). All parents should be told, or should understand, that they can come back any time if they observe or fear their children are getting worse. 

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