Acute and Chronic Cough in Children.

Cough (lat.tussis) is an automatic, natural reflex (without human will) that helps expel secretions, various irritants, foreign particles and microorganisms from the airways.In children, the most common cause of cough is the accumulation of secretions in the respiratory tract as a result of an allergy or infection.According to the duration, cough can be divided into: acute cough that lasts up to 4 weeks and chronic cough that lasts longer than 4 weeks.Most cases of acute cough in children are associated with viral infections of upper respiratory tract and do not require specific diagnostic evaluation.Treatment of upper respiratory tract infections (URTIs) requires antipyretics, good hydration and aspiration of secretions.Intranasal steroids may be effective in children with allergic rhinitis that presents with cough during the pollen season.The causes of chronic cough in children vary depending on the age of the patient.The most common cause of non-specific chronic cough in children under 5 years of age is as a result of upper respiratory tract infection (37.6%), followed by asthma-like cough (31.8%) and post-infectious cough (18.8%).Chronic cough due to asthma requires treatment with bronchodilators and, depending on the classification, inhaled corticosteroids.In the case of allergic rhinitis, antihistamines and topical corticosteroids will be needed, at least for a month.The use of antihistamines has been shown to be very effective in patients with allergic cough.And that in groups of children with allergic asthma, allergic rhinitis and asthma, allergic rhinitis without asthma and atopic cough Treatment of allergic cough usually lasts about six months.

Cough as a symptom is one of the most common reasons for acute presentations to doctors. The burden of illness (number of presentations to doctors, impaired quality of life, and stress to parents) associated with chronic cough (>4 wk duration) in children is high and is independent of the etiology. When the chronic cough resolves, the level of stress and quality of life scores significantly improve to population norms. Moreover, chronic cough can be a symptom of an underlying serious disease such as aspiration lung disease or bronchiectasis. Thus, all children with cough require a systematic evaluation and approach. This approach, which is different from adults, is briefly outlined in this review. Physiological reasons why chronic cough in children is different from adults includes the domains that relate to (i) cough-specific physiology, (ii) general respiratory physiology, (iii) other direct systems such as the immune system that influence the respiratory system, and (iv) other general physiology. Several conditions associated with chronic cough in children have further been studied recently. These conditions that include protracted bacterial bronchitis, obstructive sleep apnea, tracheomalacia, and exercise-associated cough are also discussed in this review.

Chronic cough (a cough lasting longer than 4 weeks) is a common symptom presenting to primary care in Australia and internationally. Chronic cough costs the community, is distressing to parents, and ignoring cough may lead to delayed diagnosis and illness progression of serious underlying respiratory disease. Clinical guidelines have been shown to provide more efficient and effective patient care and can clarify clinical decision making. Cough guidelines have been designed to facilitate management of chronic cough, however treatment recommendations vary and specific clinical pathways for the treatment of chronic cough in children are important, as the cause and treatments for cough in a child vary significantly adults. Therefore, it would be beneficial to clinical practice to systematically evaluate the use of clinical pathways for the treatment of chronic cough in children. To evaluate the effectiveness of using a clinical pathway in the management of children with chronic cough. The Cochrane Register of controlled Trials (CENTRAL), the Cochrane Airways Group Specialised Register, MEDLINE, EMBASE, review articles and reference lists of relevant articles were searched. The search was carried out in May 2007. All randomised controlled trials with parallel group design comparing use vs non-use of a clinical pathway for treatment of chronic cough in children. Results of searches were reviewed against the pre-determined criteria for inclusion. Two reviewers independently selected the studies and it was planned that data extraction would have been done in duplicate. The search identified 471 potentially relevant titles but no studies met criteria for inclusion in the review. Without further available evidence, recommendations for the use of clinical pathways for the treatment of chronic cough in children cannot be made. Until further evidence is available, the decision for further investigation and treatment for the child presenting with chronic cough should be made on an individual basis (i.e. dependent on symptoms and signs) with consideration for existing data from other Cochrane reviews on specific treatments for cough. Trials are required to provide evidence on the effectiveness of clinical pathways for the treatment of chronic cough in children.

IntroductionCough is a common presenting symptom to doctors and has significant direct financial cost to thecommunity. The additional cost to families of sleep disturbance and work absenteeism should beconsidered although studies of the tangible burden of paediatric chronic cough are not available.The 1998 American College of Chest Physicians (ACCP) guidelines suggested “the approach tomanaging chronic cough in children is similar to adults”. Similarly in children, they stated, theaetiologies appeared to be the same as in adults (predominantly asthma, upper airway coughsyndrome (UACS) and gastroesophageal reflux disease (GORD)) although acknowledging therewas a paucity of data. Prospective studies looking at the investigation and causes of chronic coughin children are needed to support, or refute, these statements.The major hypothesis of this thesis is that the aetiologies and burden of illness in chronic childhoodcough is different to that described in adults.AimsThe specific aims of this thesis were:1. To examine the burden of chronic cough, and psychological influences (anxiety,depression, stress), in parents of children with chronic cough.2. To describe the aetiology of cough in our paediatric cohort using a pre-specified pathway.3. To evaluate the utility of specific cough pointers, chest radiograph and spirometry inpredicting underlying aetiologies of childhood cough.4. To examine in depth the microbiology, selected inflammatory markers and innate immunitysignaling receptors of protracted bacterial bronchitis.5. To perform a systematic review using Cochrane methodology of the efficacy of antibioticsin the management of children with chronic moist cough.6. To evaluate the effect of filtration of bronchoalveolar lavage (BAL) on reportedmeasurements.MethodsClinical cohort studyA prospective cohort of children referred to a tertiary hospital with >3 weeks chronic cough wererecruited. The study design included investigation via a pre-specified pathway using a standardizeddata collection sheet, flexible bronchoscopy and BAL as well as other investigations.Burden cohort studyParents of children newly referred for chronic cough completed 3 questionnaires (Spencer anxietyscale, depression, anxiety and stress scale (DASS) and burden of cough questionnaire) whenenrolled and, a subgroup, at follow-up.BAL methodologyBAL was divided into two aliquots and one was filtered prior to further identical processing.Airway cytology, microbiology and inflammatory mediators were evaluated in all children. In asubgroup of children innate immunity signaling receptor expression was assessed. A BAL controlgroup was also collected.ResultsChronic cough in children was associated with recurrent doctor visits (53% >10 visits) and burdenscores correlated to parental DASS scores when their child was coughing. Stress was the largestcontributor to parents’ emotional distress. The best historical predictor of specific disease was amoist cough at the time of initial consultation.A cohort of children were evaluated using a pre-specified algorithm and the most common finaldiagnosis found in children was protracted bacterial bronchitis (PBB) (39.8%). Children with PBBhad marked airway neutrophilia and increased median cytokine levels when compared with coughthat resolved naturally and no cough controls. The values for toll-like receptor (TLR)-2 and TLR-4mRNA expression were significantly elevated in children with PBB.Limited randomized studies of children with chronic moist cough showed pooled odds ratio (OR)was 0.13, 95% CI 0.06 to 0.32 for proportion of children not cured at follow-up which translates toa number needed to treat of 3. BAL filtered samples did not agree with unfiltered samples as thelimits of agreement were too wide.ConclusionChronic cough in children is associated with high burden and parental stress which resolves whencough ceases. Parents of children with chronic cough did not have above average anxiety which isin contrast to adults with chronic cough. The adult-based anatomical pathway, which involvesinvestigation and treatment of asthma, GORD and UACS first, is largely unsuitable for use in themanagement of childhood chronic cough as the common aetiologies in children are different toadults. PBB is a common paediatric condition which presents with chronic moist cough and itsairway profile is characterized by intense neutrophilic airway inflammation with markedinflammatory mediator response and evidence of innate immune activation. Antibiotics are likely tobe beneficial in the treatment of children with chronic moist cough but further randomized studiesare needed.

Respiratory symptoms such as cough, wheeze and stridor frequently occur in children and may persist for a long time. Determining the underlying cause of these chronic symptoms can be difficult as they may be due to a series of unrelated respiratory infections occurring in close succession or there may be one discrete underlying infection or condition. A chronic cough can generate anxiety in both children and their carers and ignoring it could lead to diagnostic delay or progression of a serious underlying respiratory disease. Cough guidelines and clinical pathways for a chronic cough in children vary and are not evidence based, so decisions regarding the investigation and treatment of the child with a chronic cough need to be made on an individual basis. This article provides a structured approach to managing the presentation of a chronic cough in children in general practice.

Chronic respiratory disease is common among Aboriginal Australians. Chronic wet cough is an early marker of chronic disease in children but often goes undetected due, in part, to delayed health seeking by families. Currently, no studies have examined the reasons for delayed health seeking for children's chronic cough. To identify the barriers to, and enablers for, seeking medical help for chronic wet cough in Aboriginal children. This was a qualitative study, gathering data through individual semi-structured, in-depth interviews and focus groups to ascertain Aboriginal family knowledge, attitudes and beliefs about seeking health care for chronic wet cough in children in a regional Kimberley town, Western Australia between October 2017 and March 2018. Forty Aboriginal community members participated. The three key barriers identified were: 'Cough normalisation', that is, 70% of participants considered chronic cough normal (with 53% of participants' previous interactions with doctors informing their understanding of chronic cough); the lack of health literacy information; and a sense of disempowerment (belief that no medical action would be taken and inability to challenge doctors). The key expressed enablers were provision of health literacy information and health practitioner training to assess and treat chronic wet cough in children. All participants reported that they would seek help for chronic wet cough once they were informed that it could signify underlying disease. Results highlight the need for a culturally appropriate information and education to inform Aboriginal families and their health practitioners of the importance of chronic wet cough in children.

Etiological factors of chronic cough in children: Don’t ignore obstructive sleep apnea

Chronic cough is a common problem of various etiologies. While diagnosis may relatively be easy in the presence of some specific findings, it tends to be rather difficult when there are no clear symptoms. Therefore, practical guidelines are needed for management of patients with chronic cough. We aimed to evaluate assessment and management of chronic cough in children according to the British Thoracic Society guidelines published in 2008. Patients with chronic cough lasting longer than 8 weeks between 5 and 16 years old were evaluated. Pulmonary function test and chest radiography were performed on all patients. Further workup was conducted on those requiring further investigation. Patients were re-evaluated at 2- to 4-week intervals, and we followed our patients for 18 months until cough resolved. One hundred fifty six patients (52.5% female) aged 5-16 (8.42 ± 2.6) years were included. Of the 156 patients, 19.2% (n = 30) were diagnosed with postnasal drip syndrome plus asthma; 18.6% (n = 29) with postnasal drip syndrome; 12.2% (n = 19) with asthma; 12.2% (n = 19) with protracted bacterial bronchitis; and 11.5% (n = 18) with nonspecific isolated cough, 9.6% (n = 15) with cough variant asthma, 5.7% (n = 9) with psychogenic cough and 3.2% (n = 5) with gastroesophageal reflux disease. Postnasal drip syndrome and asthma was the most common cause of chronic cough. Asthma-associated findings were found in some of the patients diagnosed with postnasal drip syndrome. It has been observed that there could be more than one particular cause for cough concerning some patients. The gastroesophageal reflux disease was not a common primary cause of chronic cough in children.

BackgroundAcute respiratory illness, a leading cause of cough in children, accounts for a substantial proportion of childhood morbidity and mortality worldwide. In some children acute cough progresses to chronic cough (>4 weeks duration), impacting on morbidity and decreasing quality of life. Despite the importance of chronic cough as a cause of substantial childhood morbidity and associated economic, family and social costs, data on the prevalence, predictors, aetiology and natural history of the symptom are scarce. This study aims to comprehensively describe the epidemiology, aetiology and outcomes of cough during and after acute respiratory illness in children presenting to a tertiary paediatric emergency department.Methods/designA prospective cohort study of children aged <15 years attending the Royal Children’s Hospital Emergency Department, Brisbane, for a respiratory illness that includes parent reported cough (wet or dry) as a symptom. The primary objective is to determine the prevalence and predictors of chronic cough (≥4 weeks duration) post presentation with acute respiratory illness. Demographic, epidemiological, risk factor, microbiological and clinical data are completed at enrolment. Subjects complete daily cough dairies and weekly follow-up contacts for 28(±3) days to ascertain cough persistence. Children who continue to cough for 28 days post enrolment are referred to a paediatric respiratory physician for review. Primary analysis will be the proportion of children with persistent cough at day 28(±3). Multivariate analyses will be performed to evaluate variables independently associated with chronic cough at day 28(±3).DiscussionOur protocol will be the first to comprehensively describe the natural history, epidemiology, aetiology and outcomes of cough during and after acute respiratory illness in children. The results will contribute to studies leading to the development of evidence-based clinical guidelines to improve the early detection and management of chronic cough in children during and after acute respiratory illness.

Cough is one of the most common reasons leading to pediatric consultations, negatively impacting the quality of life of patients and caregivers. It is defined as a sudden and forceful expulsion of air from the lungs through the mouth, typically triggered by irritation or the stimulation of sensory nerves in the respiratory tract. This reflex is controlled by a neural pathway that includes sensory receptors, afferent nerves, the brainstem’s cough center, efferent nerves, and the muscles involved in coughing. Based on its duration, cough in children may be classified as acute, lasting less than four weeks, and chronic, persisting for more than four weeks. Neuromodulators have shown promise in reducing the frequency and severity of cough by modulating the neural pathways involved in the cough reflex, although they require careful monitoring and patient selection to optimize the outcomes. This review aims to examine the rationale for using neuromodulators in the management of cough in children.

Cough is a natural process that protects the airway. Cough can occur spontaneously or voluntarily. It is considered chronic when it is present for longer than 4 weeks in children or 8 weeks in adults. In both, chronic cough causes patient distress and increased healthcare utilization. Etiologies of pediatric chronic cough include asthma, protracted bacterial bronchitis, tracheomalacia, habit cough, and various systemic disorders. While some diagnoses are identifiable by careful history alone, others require testing guided by specific pointers. Flexible fiberoptic bronchoscopy has been an important tool to identify etiologies of chronic cough that were not otherwise apparent. In adults, asthma and bronchitis are well-defined etiologies of chronic cough, but much chronic cough in adults is largely a conundrum. Reviews of adult chronic cough report that at least 40% of adults with chronic cough have no medical explanation. Gastroesophageal reflux and upper airway cough syndrome (a.k.a. post-nasal drip) have been common diagnoses of chronic cough, but those diagnoses have no support from controlled clinical trials and have been subjected to multiple published critiques. Cough hypersensitivity is considered to be an explanation for chronic cough in adults who have no other confirmed diagnosis. Gabapentin, a neuromodulator, has been associated with a modest effect in adults, as has speech pathology. While habit cough has not generally been a diagnosis in adults, there is evidence for a behavioral component in adults with chronic cough. Treatment for a specific diagnosis provides a better outcome than trials of cough suppression in the absence of a specific diagnosis. More data are needed for chronic cough in adults to examine the hypothesized cough hypersensitivity and behavioral management. This article reviews etiologies and the treatment of chronic cough in children and the conundrum of diagnosing and treating chronic cough in adults.

Introduction and ObjectivesAmbulatory 24 h cough monitoring is a relatively new technique, and so far few studies have investigated hourly variation in cough frequency. We analysed data from previous studies...

Chronic cough in children is common and frequently mismanaged. In the past, cough was diagnosed as asthma and inappropriate asthma therapies prescribed and escalated. It has been realized that persistent bacterial bronchitis (PBB) is a common cause of wet cough and responds to oral antibiotics. The initial definition comprised a history of chronic wet cough, positive bronchoalveolar (BAL) cultures for a respiratory pathogen and response to a 2-week course of oral amoxicillin–clavulanic acid. This is now termed PBB-micro; PBB-clinical eliminates the need for BAL. PBB-extended is PBB-micro or PBB-clinical but resolution necessitating 4 weeks of antibiotics; and recurrent PBB is >3 attacks of PBB-micro or-clinical/year. However, the airway has only a limited range of responses to chronic inflammation and infection, and neutrophilic airway disease is seen in many other conditions, such as cystic fibrosis and primary ciliary dyskinesia, both chronic suppurative lung disease endotypes, whose recognition has led to huge scientific and clinical advances. There is an urgent need to extend endotyping into PBB, especially PBB-recurrent. We need to move from associative studies and, in particular, deploy sophisticated modern –omics technologies and systems biology, rather as has been done in the context of asthma in U-BIOPRED. In summary, the use of the term PBB has done signal service in pointing us away from prescribing asthma therapies to children with infected airways, but we now need to move beyond a simple description to teasing out underlying endotypes.

<b>Background:</b> While some diagnoses of chronic cough in children are made by careful history alone, others require further investigations. Flexible fibreoptic bronchoscopy has been an important tool to identify the etiology of chronic cough that is not otherwise apparent. <b>Methods:</b> Over 20 years, we evaluated retrospectively a population of 176 children with chronic cough not related to asthma who were referred to a specialized center (2012-2021). All patients were evaluated with chest radiographs (CXRs), spirometry, HRCT scanning, and FB/BAL. <b>Results:</b> We evaluated 176 children with chronic cough (53% males, median age six years, 1 -to 18 years), median BMI 17.8kg/m2), mean (SD) FEV1pp 89.3 (35) %. Flexible bronchoscopy indicated the etiology of chronic cough in 84% of the cases; diagnosis included: tracheobronchomalacia (14%), bronchomalacia (13%), tracheomalacia (14%), laryngomalacia (6.5%), stenosis of the RML bronchus (12.5%), other congenital anomalies of the trachea-bronchial tree (12%), suspicion of vascular ring (1%), inflammation of the airways &amp; secretions of the airways (11%) and normal findings (16%). Following the diagnosis, the children received appropriate treatment. As a result, the symptoms were significantly improved and follow-up spirometry indices were also significantly improved 1.6years later (mean (SD) ΔFVCpp 25.6 (13), ΔFEV1pp 25.8 (11), p&lt;0.001. <b>Conclusions:</b> Pediatric FB is an essential tool for diagnosing children with chronic cough. Underline anatomical conditions were found in many children with chronic cough, significantly impacting further patient management.

What Is the Burden of Chronic Cough for Families?