1. An attempt should be made to arrive at a specific diagnosis for any child presenting with acute cough that started less than three weeks previously.
Possible diagnoses include viral head cold, croup syndrome, allergic rhinitis and lower respiratory illness.
In most children, cough is due to a simple upper respiratory tract infection and will not need any investigations. The absence of fever, tachypnoea and chest signs are the most useful for ruling out future complications.
2. There are clear indications for earlier investigation in acute cough.
These are:
• acute onset with witnessed choking (inhaled foreign body)
• haemoptysis
• progressive cough not improving or worsening after two weeks – consider TB or pertussis
• suggestion of underlying chronic lung disease on examination – such as failure to gain weight, finger clubbing and chest deformity.
3. Most children's coughs will resolve within a fortnight, but some can last up to four weeks.
Informing parents of this will help minimise subsequent attendances, but parents should know to reattend if the child continues to have fever or tachypnoea, or the cough gets worse. Symptomatic cough can develop between seven and 10 episodes per year in school-age children, with symptoms lasting approximately 10-14 days, without complications.
4. Be aware of the ‘red flags'.
These include:
• early onset – especially from birth
• cough associated with feeding or eating
• sudden onset
• chronic moist cough with phlegm
• night sweats with or without weight loss
• unremitting or worsening cough
• signs of chronic disease – finger clubbing, weight loss, chest deformity.
5. A chronic cough lasting longer than eight weeks demands a diagnosis.
A detailed history and examination is essential. Try to observe the cough and get a sputum sample if possible – it is difficult in children under five, but phlegm may be seen in an associated vomit.
6. There are no effective medications for acute cough associated with head colds – whether over-the-counter medications, bronchodilators or antibiotics.
Antihistamines or intranasal steroids may be beneficial for children with allergic cough during pollen season.
7. Be wary of the asthma misdiagnosis.
Most children with isolated non-specific cough with no wheezing, and who are otherwise well, do not have asthma and do not respond to asthma therapy.
But cough variant asthma does exist – usually with a history of atopy – and it's reasonable to give a six- to eight-week trial of medication, for example inhaled beclomethasone 200 µg BD and a bronchodilator.
Even responders should have this trial stopped as the cough may have resolved during the trial. Consider cough variant asthma if the cough relapses and responds again to asthma therapy.
8. Children with chronic or recurrent ‘wet' or productive cough may have a more serious lung disease.
They need to be referred to have conditions such as cystic fibrosis, immune deficiencies, primary ciliary dyskinesia and persistent bacterial bronchitis excluded.
The latter is a relatively new term that describes a condition in children with chronic productive cough associated with neutrophils and bacteria in bronchoalveolar lavage fluid, which responds rapidly to a two- to six-week course of antibiotics – for example, co-amoxiclav.
9. Psychogenic cough usually affects older children.
It is often a bizarre pattern of cough, which does not occur during sleep or when distracted, and worsens with attention.
There is a fine line between doing investigations to rule out a possible underlying disease, without performing too many unnecessary tests that could potentially reinforce the problem.
10. These presentations are a chance to address parental smoking.
Smoking in the home should be addressed during the consultation and cessation advice and support should be given as required.
Professor Michael Shields is professor of child health at the Queen's University of Belfast
Dr Bernadette O'Connor is paediatric respiratory registrar at the Royal Belfast Hospital For Sick Children
Further reading
Shields MD, Bush A, Everard ML et al. Recommendations for the assessment and management of cough in children. Thorax 2008;63:iii1-15
