My Child & I : The Coughing Child
One of the most common reasons for concerned parents visiting the doctor is a coughing child. Coughs are one of the most frequently encountered symptoms in the primary care setting and when seen in a child can be a source of great anxiety. We’ll try to address some common causes of cough here as well as present some remedies that may be of use.
What is a cough?
Simply put, a cough is a reflexive action that tries to expel irritants out of the lungs. It does this by creating a rapid burst of exhaled air. Coughs are triggered by airway irritation from fluids, secretions, inhaled particles or foreign bodies. Based on how long a cough has persisted, we can classify them into:
Acute : A cough lasting less than 3 weeks
Subacute : A cough lasting from 3 to 8 weeks
Chronic : A cough lasting more than 8 weeks
Coughs can also be categorized according to their causes, or whether they produce mucus or not.
What’s causing the cough?
Obviously, the biggest concern of the parent of a coughing child is figuring out how to make their child well. In order to do this, we need to understand what causes a cough and how each can be managed.
Respiratory Tract Infections
By large, the most common reason for an acute/subacute cough is a respiratory tract infection (RTI). There are many known causative organisms of RTIs. The most common reasons are viruses like rhinovirii and adenovirii. Other important pathogens are:
Pertussis (aka whooping cough)
Haemophilus influenza B
to name a few.
RTI related coughs often have other accompanying symptoms such as fever, corzya (running nose), sore throat and rashes. They may also cause the child to be irritable and feed poorly. Persistent coughing may even lead to vomiting. RTI related coughs tend to be limited to the duration of the underlying infection. However, in certain instances airway sensitivity may persist and result in a post-infectious cough which can remain for a few weeks.
One form of RTI related cough is bronchiolitis. It is a common condition, unique to children younger than 2 years of age. It presents with fever, cough and breathlessness. Bronchiolitis is usually caused by viral RTIs and causes inflammation of the bronchioles, the smallest air passages of the lungs. Owing to the immature state of the lung, this can lead to small airway collapse, resulting in wheezing and breathlessness.
Much like other RTIs, bronchiolitis tends to be self limiting. While the initial illness usually subsides in less than a week, the cough itself may persist for 2-3 weeks after.
Asthma / Allergic rhinitis
Asthma is probably the second most common cause of cough presentations and the most common cause of recurrent coughs. Asthma is characterized by respiratory hyper-secretion and airway hypersensitivity. In older children (and adults) it usually presents with wheezing, shortness of breath and cough, but in younger children , cough may be the only presenting symptom. Asthmatic coughs can be triggered by a number of allergen/irritants unique to each individual. Common triggers are:
amongst others. Asthma can also be triggered or worsened by RTIs. Asthmatic coughs usually do not have an associated fever unless RTIs are a trigger factor. It is common for children who have asthma to have other hypersensitivity diseases such as eczema or allergic rhinitis. Indeed, in younger children it is difficult to differentiate between asthmatic cough and coughs resulting from respiratory allergies.
Unlike RTI related coughs, asthmatic/allergic coughs tend to be chronic and or recurrent. Severe disease may also be associated with failure to thrive, resulting in a child with slow growth and development.
Gastroesophageal Reflux Disease (GERD)
GERD coughs are yet another common cause of chronic coughs, especially in infants and younger children. Reflux occurs when gastrointestinal fluids leak upwards from the stomach into the esophagus. This can happen more frequently in young children, whose immature smooth musculature can result in incomplete sealing of the esophageal outlet, letting such leaks happen more easily. When the GI fluids reach the oropharynx ( back of the throat), there may be a spillover effect into the respiratory passages, resulting in irritation and thus provoking a cough.
GERD coughs are commonly noted to be worse on waking up and going to bed, owing to the positional changes that most affect the leak of GI fluids. GERD coughs can also frequently persist through the night. Other associated symptoms of colic, poor feeding, frequent vomiting, gagging or choking when feeding and failure to thrive may also be present.
Foreign bodies (FBs)
Swallowing FBs is an uncommon yet important cause of coughing to rule out. Swallowing foreign bodies can be a behaviour seen in all children but is most commonly witnessed in children between 6 months and 5 years of age. The most common objects swallowed are coins. Most of the time swallowed FBs will transit through the GI system without ill effect, but occasionally they may travel into the airways and get lodged and cause acute coughing or suffocation. Rarely,swallowed FBs may get trapped in the lung passages and become a source of recurrent or severe infection.
Imaging such as an Xray or CT may help identify the site of the trapped FBs. In some cases surgery may be required to remove an FB lodged in the respiratory passages.
Coughs may be to due to variety of reasons. Some less frequent causes of cough include:
Bronchodysplasia : Congenital malformations of the air passages
Cystic Fibrosis : Rare in Asian populations
Psychogenic cough : aka habitual cough, nervous tic
Hypereosinophilic syndrome (HES)
How do I treat the cough?
In order to treat a cough, we must first identify its cause. A detailed history including details about nature and duration of cough, associated symptoms, triggering and/or relieving factors are useful in determining its cause. A focused physical examination may also help in figuring out the cause.
Tests may also be useful in determining the cause of the cough. Some common investigations include:
Full blood count : Useful in determining infective causes as well as signs of hypersensitivity
Chest Radiograph : Useful in determing patterns of infection/ deep FBs
Neck Radiograph : Useful if FB aspiration is suspected.
Spirometry : Useful assessment of lung function in older children
Allergy testing : if allergic cough/ airway hypersensitivity is suspected.
In general, management of a cough involves addressing its underlying cause as well as symptomatic management. Here are some general measures and medications that can be used to help treat a cough.
Avoid dusty, smoky environments
Encourage the child to drink warm fluids
Where possible, let the child rest in a well ventilated room. Avoid using the air-con if possible
Elevate the head of the child when resting by using additional pillows. In infants and younger children, this can be done by placing a pillow under the mattress of the cot.
Where possible, allow the child to gargle with warm water mixed with salt.
For children older than 1 year, give warm water mixed with honey to drink.
Steam inhalation can help alleviate airway congestion and ease coughing.For best results, add Mentholatum or camphor to the steam.
On occasion, children may need medications to help alleviate their symptoms. Here are some medication classes and common uses for them. Note that many cough medications may contain a combination of these classes.
Antihistamines/Decongestants : These medications can help reduce respiratory secretions as well as reduce coughing. Commonly used antihistamines are cetrizine, chlorpheniramine and promethazine. Pseudoepherine is a commonly used symptatomimetic decongestant.
Antitussives : Antitussives are groups of medication that work through various means to reduce or suppress the cough reflex. This is useful in children with dry coughs or persistent coughs preventing sleep. Commonly used antitussives are dextromethorphan and opioid derivatives such as codeine.
Expectorants : In contrast to antitussives, expectorant mixtures help to expel the accumulating irritant respiratory secretions from the lung. This sometimes leads to the false impression that expectorants worsen the cough, while in fact they seek to hasten resolution by getting rid of the inflammatory debrii as quickly as possible. Guaifenesin is a commonly used paediatric expectorant.
Mucolytics : Mucolytics work to help reduce airway irritation caused by accumulation of respiratory secretion. Unlike expectorants, mucolytics do not directly help expel mucus. Instead, they break the long protein chains found in the mucus, making easier for the body to expel or reasbsorb the secretions. Mucolytics are one of the more commonly used medications, especially in younger children. Commonly used mucolytics include ambroxol, bromhexine and acetylcysteine.
Bronchodilators : Bronchodilators are used to relieve airway spasm and are primarily used for asthmatic or allergic coughs. However, they can give good relief of respiratory symptoms, particularly in younger children. Bronchodilators can be taken orally or as an aerosol via inhalers/nebulisers.
Corticosteroids : Corticosteroids are powerful antiinflammatory agents and thus are very effective in reducing coughs and secretions, particularly for symptoms that are persisting for some time However, they can have many wide-ranging side effects on the body, including gastrointestinal irritation and even growth suppression in overuse. For this reason, it is best preferred to use as little of a corticosteriod as possible. Using aerolosized delivery greatly reduces the total dose of steroid given and limits its area of activity to the desired target (i.e. The lungs). For children unable to tolerate inhalers/nebulisations, short pulsed courses of milder oral steroids such as prednisolone are preferred. One newer option is the use of leukotreinereceptor inhibitors such as monteleukast (Singulair ®) which offers many of the benefits of corticosteroids but with far fewer side effects.
Coughs are a very common complaint in both young and old. Managing a child’s cough can be particularly challenging, as they tend to last longer and often affect the child’s feeding and overall well-being. Knowing some basic management techniques can greatly help ease your child’s distress and speed their journey back to wellness.
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