Patient Presentation
A 9-month-old female came to clinic with her parents for her health supervision visit. They were concerned about chronic infections she had over the past 6 months, particularly a cough. “It just doesn’t seem to go away. She has it and it goes on for a few weeks, then it seems to be getting better, and she seems to get sick again and we start all over,” her mother complained. “Yeah, then she has diarrhea once in a while and she had an ear infection. She’s out of daycare more than she is in it seems like. See she has a runny nose for the past 4 days,” her father explained. “She was fine until I went back to work when she was around 3 months of age. She got the first cough the second week of daycare,” her mother recounted. The cough generally didn’t seem to bother her but when she had more rhinorrhea she would awaken more frequently during sleep. The coughing did not affect her eating or play. They denied any reflux symptoms except when she had had a diarrheal illness where she also had one episode of emesis. The past medical history showed one visit for otitis media at 5 months of age, one diarrhea visit at 4 months of age and 3 visits for cough. The family history was non-contributory including no history of eczema, asthma, or allergies, and her review of systems was unremarkable.

The pertinent physical exam showed a smiling toddler with growth parameters around the 75% and tracking. She has mild clear rhinorrhea. Her skin and lung exams were normal as was the rest of her examination.

The diagnosis of a healthy female with a chronic cough due to presumed recurrent viral infections was made. The patient’s clinical course over the next year, showed that she continued to have some intermittent viral infections but fewer in number and she continued to not have any other problems including having continued normal growth and development.

Discussion
Coughing is a normal process. It protect and cleans out the airway, making breathing and oxygenation possible. Irritation and stimulation of the cough receptors can be stimulated by many things including mucous, foreign bodies or infectious agents. Coughing is due to the sudden release of air that was compressed behind a closed glottis. The sound can vary considerably by its loudness, timbre and pitch. People will describe a “wet” cough as one where mucus is heard or is produced, whereas this is absent in a “dry” cough. Acute coughs are defined as < 4 weeks and chronic coughs are defined as > 4 weeks in children. In adults this is increased to > 8 weeks.

A general overview of cough can be found here

Some common causes by type of cough:

• Wet
  • Asthma
  • Infection
  • Bronchiectesis
  • Cystic fibrosis
  • Primary ciliary dyskinesia
• Dry cough
  • Asthma
  • Allergy
  • Habit
• Paroxysmal
  • Habit
  • Pertussis
• Barky
  • Croup
  • Habit
  • Anatomic problems such as tracheomalacia

Signs or symptoms that can indicate a specific cough which can point to a more specific disease process include:

• Abnormal breathing – dyspnea or tachypnea
• Cardiac disease
• Chest pain
• Cyanosis or hypoxia
• Chest wall deformities
• Clubbing of the digits
• Failure to thrive
• Feeding problems
• Hemoptysis
• Immune deficiency
• Pneumonia, recurrent
• Neurodevelopmental delay

Learning Point
For the general pediatrician, recurrent viral infections with rhinorrhea, environmental allergies, asthma/bronchospasm and gastroesophageal reflux disease (GERD) are some of the most common problems presenting as chronic cough. These may have overlap such as recurrent viral infections may have continued rhinorrhea stimulating the cough mechanism. This in turn may also cause irritation leading to bronchospasm and/or asthma exacerbation. Allergies and allergic rhinitis as triggers are similar. Gastroesophageal reflux disease is also a common problem because of the regurgitated stomach contents causing irritation which stimulates the cough reflex. This also potentially can cause aspiration as well.

Viral infections usually resolve in 4-6 weeks but often are recurrent because of exposure such as in daycare or school situations. Healthy children have somewhere between 4-8 viral infections per year.

Evaluation and treatment for chronic cough in children is usually by looking at a presumptive diagnosis and evaluating/treating accordingly. Continued detailed history, objective testing when available (e.g. peak flow monitoring), and follow up are needed.

The differential diagnosis of chronic cough includes:

• Viral/post-viral – upper respiratory cough syndrome
  • These increase mucous production and nasal inflammation.
• Allergy, Allergic rhinitis
  • Can be difficult to discern from recurrent viral infections or asthma especially if due to a year-round cause such as mold or daily allergy
• Asthma/bronchospasm including smoke exposure or other triggers
  • Varies by type but can be wet or dry with different frequencies
  • May only occur in certain venues or circumstances such as when exercising or if triggered by viral infection, rhinitis or smoke exposures
  • Improvement with course of short-acting bronchodilator can help support the diagnosis but an improvement with a course of oral steroids is very supportive of the diagnosis.
  • A review can be found here
• Attention seeking or imitation
• alpha-1-Antitrypsin deficiency
• Anatomic – congenital heart disease, aberrant innominate artery, tracheoesophageal fistula, pulmonary sequestration
• Bronchomalacia including tracheomalacia, tracheobronchomalacia and similar problems <ul
• A review of airway malacia presentations can be found here

Bronchiectesis

• Wet cough that is usually accompanied by chronic lung diseases such as cystic fibrosis but can be seen by itself.
• Digital clubbing may be associated with it.
• A review of digital clubbing can be found here

Cystic fibrosis

• Wet chronic cough that may be accompanied by other problems such as failure to thrive
• Diagnosis is commonly made with newborn screening for the cystic fibrosis transmembrane regulator (CTRF gene) but still needs to be considered.

Primary immunodefiency

• Parents are often concerned that their child has an immunodeficiency when they have recurrent viral infections.
• Serious or unusual infections, or family history are common reasons to consider an immunodeficiency evaluation.
• A review of presentations can be found here

Primary ciliary dyskinesia

• Wet cough since birth that begins early in infancy and continues
• May occur with changes in the lateralization of organs (i.e. situs inversus)

Habit cough/psychogenic cough

• Varies in type but can be loud or soft, barky or honking sometimes and varies in the frequency from several times/minute to more intermittently.
• Key point is that it only occurs when the patient is awake and goes away with sleep.
• A review of the treatment of habit cough can be found here

Airway foreign body aspiration

• This can have a sudden onset but often can be chronic especially if the aspiration is due to a small organic or non-organic object
• Radiographs may be helpful to note radioopaque objects or air trapping
• A review about foreign bodies can be found here

GERD and laryngopharyngeal reflux

• Cough can be varied but often is accompanied simultaneously with regurgitation.
• Entities that cause increased regurgitation include esophageal achalasia and hiatial hernia
• A review can be found here

Medications – angiotension-converting enzymes, calcium channel blockers, nasal sprays

Pertussis

• Due to Bordetella pertussis and can occur for 3 months.
• Usually has harsh coughing spells called paroxysms. It can sound similar to a habit cough but is also present at night

Protracted bacterial bronchitis

• Diagnosed by specific findings on bronchoalveolar lavage
• Sometimes treatment with a course of antibiotics is also used as a presumptive treatment and diagnostic evaluation.
• Common organisms are Haemophilus influenza, Moraxella catarrhalis, and Streptococcus pneumoniae

Sinusitis

• This can be worsened by large adenoids or tonsils
• Treatment for presumed chronic rhinosinusitis includes saline irrigation, nasal steroids and possibly antibiotics

Tics

• A review can be found here

Tuberculosis

Vocal cord dysfunction

• A review can be found here

Questions for Further Discussion
1. What are indications for referral to a pulmonologist or otolaryngologist for chronic cough?
2. At what age can you start to do reliable pulmonary function tests?
3. What vaccines or medication are available to treat potentially cough inducing infections?
4. How do you use over-the-counter cough medicines?

Related Cases

Disease: Viral Infections | Cough

Symptom/Presentation: Cough

Specialty: General Pediatrics | Allergy / Pulmonary Diseases

Age: Infant

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

Evidence-based medicine information on this topic can be found at SearchingPediatrics.com and the Cochrane Database of Systematic Reviews.

Information prescriptions for patients can be found at MedlinePlus for these topics: Viral Infections and Cough.

To view current news articles on this topic check Google News.

To view images related to this topic check Google Images.

To view videos related to this topic check YouTube Videos.

Chang AB, Oppenheimer JJ, Weinberger M, et al. Etiologies of Chronic Cough in Pediatric Cohorts. Chest. 2017;152(3):607-617. doi:10.1016/j.chest.2017.06.006

Kennedy AA, Anne S, Hart CK. Otolaryngologic Management of Chronic Cough in School-aged Children: A Review. JAMA Otolaryngol Head Neck Surg. 2020;146(11):1059. doi:10.1001/jamaoto.2020.2945

Weinberger M, Hurvitz M. Diagnosis and management of chronic cough: similarities and differences between children and adults. F1000Res. 2020;9:F1000 Faculty Rev-757. doi:10.12688/f1000research.25468.1

Author
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa