A 4-year-old female came to clinic for her health supervision visit. She was doing well but the parents reported that she seemed to have a cough. They said that they noticed it around birth and it had never improved. It occurred mainly around feeding times at day and night and they had not tried anything specifically to help the cough. They denied rhinorrhea, sweating, or color changes. They said that she seemed to have more spitting up than their other child and she seemed uncomfortable after feedings, so they had been placing her in an upright infant seat. A babysitter came to her house for childcare. The past medical history showed a full term infant with no prenatal or natal complications. She was growing normally at her 2 month visit and had received her immunizations. The family history was negative for congenital anomalies or asthma. The review of systems was negative including no recent illnesses.
The pertinent physical exam showed a smiling female whose weight was continuing to grow at the 50th percentile, and head circumference and length were 75%. HEENT and lung examination were negative. The patient had just fed and the clinician heard the cough and noticed that the infant was spitting up at the time. The infant also did appear to be somewhat uncomfortable with the emesis. The diagnosis of an appropriately growing female infant with a cough that was probably secondary to gastroesophageal reflux was made and the patient was started on lansoprazole. At followup the parents reported that the arching/fussiness behaviors had stopped and the coughing was reduced.
“A cough is a voluntary or involuntary explosive expiration. After a deep inspiration, the glottis is closed and the expiratory muscles contract, compressing the lung and raising intrapulmonary pressure above the atmospheric pressure. The glottis then opens, and gas is expelled at a rapid rate.”
Acute coughs are commonly due to upper respiratory tract diseases in children of all ages – often because of post-nasal rhinorrhea. Chronic coughs may be more difficult to determine the cause of and may require more investigation, consultation, and/or empiric trials of medication including radiographic imaging of chest or sinuses, spirotometry, sweat chloride, methacholine challenge, bronchoscopy, gastroscopy, immunodeficiency testing, etc. Children with congenital abnormalities will often have cough but also other “noisy breathing” or “funny cries” if the abnormality affects the overall breathing apparatus. Some of the symptoms and signs which may lead to a diagnosis other than common acute upper respiratory tract disease include abnormal ausculatory findings of the lungs or heart, clubbing, chest pain, dyspnea, failure to thrive, daily wet cough, exposures to infectious disease or environmental irritants such as smoking, other congenital abnormalities, recurrent pneumonia, drug exposures, etc.
Gastroesophageal reflux is a normal physiological process where stomach contents reflux back into the esophagus which occurs multiple times per day and is cleared by gravity. Gastroesopheageal reflux disease occurs when there is an abnormality of this normal process. Go here for more information about gastroesopheal reflux disease
The differential diagnosis of cough includes:
- Allergic rhinitis
- Cleft palate
- Congenital heart disease – including vascular rings, congestive heart failure
- Laryngeal cleft
- Laryngeal – cyst, malacia, stenosis
- Pulmonary malformation – sequestered lobe
- Tracheoesophageal fistula
- Vocal cord paralysis
- Alpha-1-antitrypsin deficiency
- Cystic fibrosis
- Dyskinetic cilia
- Immunodeficiency syndromes
- Mounier-Kuhn syndrome
- Streptococcus pneumoniae
- Human immunodeficiency virus
- Respiratory syncytial virus
- Disease process
- Otitis Media
- Post-infectious cough
- Upper respiratory infections
- Drug-induced conditions
- Environmental irritants
- Foreign body aspiration
- Gastoesophageal reflux
- Post-nasal discharge
- Psychogenic or habit cough
- Swallowing dysfunction
- Tourette syndrome
- Neoplasm/Benign Tumors
- Mediastinal tumors
- Nasal polyp
Questions for Further Discussion
1. What are the definitions of acute versus chronic cough?
2. What are indications for referral to a pulmonologist?
3. What are indications for computed tomography or bronchoscopy of the lungs?
- Symptom/Presentation: Cough
- Age: Infant
To Learn More
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Fleisher GR, Ludwig S. Synopsis of Pediatric Emergency Medicine. Williams and Wilkins. Baltimore, MD. 1996:64.
Rudolph CD, et.al. Rudolph’s Pediatrics. 21st edit. McGraw-Hill, New York, NY. 2003:1910.
Woodhead JC. Pediatric Clerkship Guide. Mosby. St. Louis MO, 2003:196-197.
Goldsobel AB, Chipps BE. Cough in the pediatric population. J Pediatr. 2010 Mar;156(3):352-8.
Chang AB, Berkowitz RG. Cough in the pediatric population. Otolaryngol Clin North Am. 2010 Feb;43(1):181-98, xii.
Ramanuja S, Kelkar PS. The approach to pediatric cough. Ann Allergy Asthma Immunol. 2010 Jul;105(1):3-8.
ACGME Competencies Highlighted by Case
1. When interacting with patients and their families, the health care professional communicates effectively and demonstrates caring and respectful behaviors.
2. Essential and accurate information about the patients’ is gathered.
3. Informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment is made.
4. Patient management plans are developed and carried out.
10. An investigatory and analytic thinking approach to the clinical situation is demonstrated.
11. Basic and clinically supportive sciences appropriate to their discipline are known and applied.
17. A therapeutic and ethically sound relationship with patients is created and sustained.
18. Using effective nonverbal, explanatory, questioning, and writing skills, the healthcare professional uses effective listening skills and elicits and provides information.
19. The health professional works effectively with others as a member or leader of a health care team or other professional group.
23. Differing types of medical practice and delivery systems including methods of controlling health care costs and allocating resources are known.
24. Cost-effective health care and resource allocation that does not compromise quality of care is practiced.
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa Children’s Hospital