Basic rules Causes of prolonged cough Related causes Bibliography Translator’s commentary
Fundamental rules • A child with a prolonged cough should be examined to rule out asthma, allergies and gastroesophageal reflux, and bronchoscopy should be performed.
Causes of prolonged cough Recurrent infections • In this case, the cough is not associated with a new disease but more often is a manifestation of a new disease • Careful collection of a family history of existing diseases is required
Local infection • Cough may be the only serious manifestation of otitis media with exudate or subacute sinusitis in older children. • With sinusitis, cough often appears at night or in the morning. It is not a consequence of runoff of mucus over the surface of the pharynx, but is associated with reflex irritation of cough receptors with otitis media.
Ultrasound examination of the maxillary sinuses is a safe method recommended for re-examination • Eardrums should be examined with a pneumatic otoscope or with acoustic impedance. A simple visual inspection is insufficient. • Indications for chest radiographs should be carefully determined.
Whooping cough, mycoplasmosis, chlamydia • You should be familiar with the clinical manifestations of these infections (See EBM Guideline: “Whooping cough” available on the EBM Web site) • The cough associated with pulmonary mycoplasmosis and chlamydia can last for several weeks and resemble whooping cough
Hyperreactivity after infections • Bronchial hyperreactivity may last several weeks after viral and mycoplasma infections. The most important symptom is coughing during exercise and in cold weather. Asthma • Asthma is manifested by difficulty in breathing associated with mucosal edema and bronchospasm.
The diagnosis is obvious in such cases: • Cough is one of the manifestations of bronchial hyperreactivity in asthma • The patient suffers from coughing at night, during exercise and when in contact with cold water • It is important to pay attention to the following points: – what are the clinical manifestations – what is the nature of the exhalation and its sound phenomena (in children older obligatory auscultation on forced expiration).
– All symptoms or their absence are recorded – In children over 5 years old, it is useful to fix the maximum expiratory flow rate (MRV) for 1-2 weeks using simple devices at home – A bronchodilation test or a free load test can also be performed (See EBM Guideline: “Wheezing in children” available on the EBM Web site) • Asthma should be suspected if:
Wheezes are re-heard during auscultation in the expiratory phase of the MRV is lower than the standards given the age, gender and growth. The MRV periodically decreases by 20%. MSV is reduced by 15% after exercise and increased by at least 15% after inhalation of sympathomimetics. (Method of calculation (see Program 1 of the corresponding full text guideline available on the EBM Web site) The frequency of symptoms and the circumstances accompanying their appearance, the effectiveness of trial therapy should be recorded in the diary
In young children, trial treatment with sympathomimetics or even inhaled steroids may be the only diagnostic method.
However, the nature of the response to sympathomimetics in children under 1 year of age is not always obvious.
Foreign bodies respiratory tract • Symptomatology can be observed in a patient for weeks and months before a diagnosis is made. • When talking with a coughing patient, it is always necessary to focus on the possibility of aspiration of a foreign body. • If a foreign body is X-ray positive (which is rare), the diagnosis can be made radiographically. In other cases, bronchoscopy is required.
Other causes of cough • Children suffering from cigarette smoke may suffer from a prolonged cough. • Gastroesophageal reflux can lead to a prolonged cough. A history of ruminations in infancy. The child should be examined by an appropriate specialist, the pH should be determined, and endoscopy, if necessary • Typical manifestations of psychogenic cough: demonstrativeness, loud speech and cough in specific situations. In 10% of cases, a prolonged cough is psychogenic.
Associate attribute • Nedocromil sodium prevents bronchospasm associated with exercise (Level of Evidence = A; Evidence Summary available on the EBM Web site).
Bibliography 1. McCracken G. Panel discussion: Bronchitis and brochiolitis. Pediatr Infect Dis 1986; 5: 766-769 2. Henry R, Milner A, Stokes G, ym. Lung function after bronchiolitis. Arch Dis Child 1983; 58: 60-63 3. Kцnig P. Hidden asthma in childhood. Am J Dis Child 1981; 135: 1053-1055 4. Puhakka H, Svedström E, Kero P. ym. Tracheobronchial foreign bodies. Am J Dis Child 1989; 143: 543-545 5. Spooner CH, Saunders LD, Rowe BH. Nedocromil sodium for exercise-induced bronchoconstriction. The Cochrane Database of Systematic Reviews, Cochrane Library number: CD001183. In: The Cochrane Library, Issue 2, 2002. Oxford: Update Software. Updated frequently.
Author (s): Hannu Jalanko Article ID: P31081 (
A prolonged cough is a fairly frequent symptom in children. The danger of this condition is not only that coughing can be the first symptom of a serious pathology. Pediatricians with diagnostic difficulties often resort to unreasonable, prolonged medical treatment, which is a threat to the health of young patients. From this point of view, the diagnostic system for long-term cough in pediatric practice offered by the Finnish pediatrician in the form of guidelines (guideline) based on evidence-based medicine is of interest.
This guideline is not devoid of “white spots”. For example, banal pharyngitis and an increase in intrathoracic lymph nodes are not mentioned, as for possible causes of coughing. It is known that a long persistent cough may be a warning signal for the formation of chronic nonspecific disease of the lungs, pulmonary dysplasias, etc.
Nevertheless, the synthesis of the information below and the thoughtful reader’s own rich clinical experience will help improve the quality of the diagnosis of protracted cough in pediatric practice, and therefore we have taken the liberty to cite these recommendations in the author’s presentation and practically without cuts.