Chronic Cough

Dear Lisa,

My 5 year old daughter has been coughing for three weeks. I brought her to the Pediatrician’s office and I was told to give her an antibiotic for a sinus infection. She never got better and now her cough is worse. She’s waking up at night coughing and during the day her cough sounds terrible. Six months ago she had the same symptoms and was diagnosed with pneumonia. I am worried that the cough may be from Asthma since I have Asthma and I remembering coughing like that when I was young. I went back to the Pediatrician’s and she said that we’ll have to watch her and wait and see if she is developing Asthma. If it is Asthma, why can’t she tell now? Can the cough be from something else? Why can’t she just give her cough medicine to make her stop coughing?

“Coughing a lot”

Dear “Coughing a lot”,

It is important to find out the cause of a chronic cough in a child before administering medication. (1) In the pediatric population, a cough is considered chronic when it lasts more than 3 weeks. Since your daughter has a cough for three weeks it is necessary for her to have a complete evaluation in order to find out the source of the cough. A complete evaluation includes a physical examination, a detailed past medical history, family history, environmental history, social history and laboratory testing.

Repeated evaluations over a period of time may be necessary to ascertain the cause of a cough. It is common for healthcare practitioners to see patients for frequent follow-up visits in order to see if new symptoms develop, if the cough goes away on its own, if it worsens with exposure to triggers or if there is a response to medication.

Cough medications are not recommended because there is no clinical evidence from controlled studies that they work in the pediatric population. (2) Preparations containing Dextromethorphan or Codeine may cause nausea and vomiting which will make a child more uncomfortable. More serious side effects of respiratory suppression may also occur with these preparations. (2,3)

It is important to remember that a cough itself is a symptom and the body’s way of protecting the airway. Coughing prevents mucus from dripping into the airways. The force of a cough expels the mucus in the lungs out of the body. A cough may be a sign of inflammation of the bronchial tubes, an infection, an irritation or in some cases a habit.

A child may develop a chronic cough due to a variety of health conditions including; Asthma, respiratory infections, Pertussis, foreign body aspiration, Tuburculosis, Gastroesophageal reflux, environmental pollutants, allergies, post nasal drip, airway lesions, vascular malformations, Cystic Fibrosis or a habit. (1, 4), This is a long list and the important thing to know is that majority of cases of children with a chronic cough have Asthma, Gastroesophageal reflux or Sinusitis. (5) Sometimes the place where a child lives and travels may be a greater indicator of the cause of a cough. A study done in India found that the most common causes of chronic cough in children between ages 1 and 12 years were Asthma, Tuberculosis, Sinusitis, Pertussis, Gastroesophageal reflux and respiratory infections. (6)

Unfortunately there is no one test that determines if a child has Asthma. The diagnosis of Asthma is based on a child’s history, physical examination, clinical presentation, response to medication, family history and laboratory tests. The diagnosis is usually made after all of these factors are evaluated and only after other causes of chronic cough are ruled out. This process takes time and in most cases repeated evaluations.

Asthma is defined as a chronic inflammatory disease of the airway that results in airway obstruction in response to a trigger. Asthma is recurrent in nature and reversible. Since Asthma is expected to be recurrent, many practitioners will wait to see if symptoms reoccur and will make the diagnosis only after the child's third episode.

In response to your question about medication for the cough; cough suppressants are not recommended. A reasonable option is to give your daughter a trial of Asthma medications for 2 to 3 weeks to see if her symptoms are reversible. If a child is treated for an Asthma related cough, the cough should respond to inhaled steroids and go away within 2 to 3 weeks. (3) Other indicators that a child with a chronic cough may have Asthma include nocturnal coughing, a cough in response to a trigger (such as exercise or environmental exposure) and a history of Eczema or Allergies.

There is a strong correlation between Asthma, Allergies and Eczema. (7,8) It also has been shown that allergies are one of the most important predictors for Asthma. (8) Asthma is up to three times more likely to develop in individuals with allergic rhinitis than those without allergic rhinitis. (9) Therefore if your child has Allergies and or Eczema, this may also tilt the scales in favor of a diagnosis of Asthma.

A child has a genetic predisposition to develop Asthma if her parents or family members have Asthma, Allergies or Eczema. If one parent has Asthma, a child has a 25 % chance of developing Asthma. If both parents have Asthma there is a 50 % chance that a child will develop Asthma. Therefore, there is a probability that your daughter will develop Asthma since you have Asthma.

It must be very frustrating and worrisome watching your daughter cough. It is important to follow up with your Pediatrician and see the evaluation through to get to the bottom of the reason for her cough.

References:
(1) Nield, L, Kamat D. How to Handle Chronic Cough in Kids: A Practical Approach to the Workup. Consultant for Pediatricians. 2003; Sept:315-321.
(2) Bell, Edward. Is codeine a useful medication in pediatrics? Infectious Diseases in Children. 2006;July:12.
(3)Chang AB, Glomb WB. Guidelines for evaluating chronic cough in pediatrics. ACCP evidence-based clinical practice guidelines. Chest. 2006;129:260S-283S.
(4) Chronic Cough in Children: New Guidelines Offer New Direction. Consultant for Pediatricians. 2006; April:251-256.
(5) Hollinger LD, Sanderd A. Chronic cough in infants and children: an update. Laryngoscop. 1991;101(6, pt 1):596-605.
(6)Mogre VS, Mogre SS, Saoji R. Evaluation of chronic cough in children: clinical and diagnostic spectrum and outcome of specific therapy. Indian Pediatr. 2002;39:63-69.
(7)Hogan B, Wilson Nevin. Asthma in the School-Aged Child. Pediatric Annals. 2003. 32(1): 20-25.
(8) Kumar R The Wheezing Infant: Diagnosis and Treatment. Pediatric Annals. 2003. 32(1):30-36.
(9) Grossman J. One airway, one disease. Chest. 198;111(2suppl):11S-16S.

Lisa-ann Kelly R.N., P.N.P.,C.
Certified Pediatric Nurse Practitioner

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