Differential diagnosis. Past medical history should cover recent respiratory infections, repeated pneumonias, history of known allergies or asthma, risk factors for TB (eg, exposure to a person who has known or suspected TB infection, exposure to prisons, HIV infection, travel to or immigration from countries that have endemic infection), and exposure to respiratory irritants. Click for pdf: Approach to a child with a cough. The physician should ask about associated symptoms. In young children with sudden cough and no fever or URI symptoms, the examiner should have a high index of suspicion for foreign body aspiration. Use of nonspecific drugs for cough suppression is discouraged in children. Cough is usually classified based on its duration, quality or etiology. Cough has a high frequency in pediatrics; it tends to persist, to ... SL, Winther B: Acute cough: a diagnostic and therapeutic challenge. A cough is a forceful expulsion of air from the lungs that helps to clear secretions, foreign bodies, and irritants from the airway. The link you have selected will take you to a third-party website. Nighttime cough can indicate postnasal drip or asthma. Chronic cough, defined as daily cough of at least 4 weeks in duration, (1) can be associated with an … Lung examination focuses on presence of stridor, wheezing, crackles, rhonchi, decreased breath sounds, and signs of consolidation (eg, egophony, E to A change, dullness to percussion). 2010 Jan; 188 Suppl 1:S33-40. Miles Weinberger, M.D., and Anthony Fischer, M.D., Ph.D. ABSTRACT. A barky cough suggests croup or tracheitis; it can also be characteristic of psychogenic cough or a postrespiratory tract infection cough. It is important, however, to differentiate between acute … Mechanoreceptors are sensitive to touch or displacement and are located mainly in the proximal airway such as larynx and trachea. 1. In Canada, croup season peaks over the fall and winter (3, 8, 9). ), For acute cough, the most common cause is, For chronic cough, the most common causes are. Acute upper / lower respiratory tract infection (ARI), Inhalation injury (acute exposure to smoke or volatile substances), Interstitial lung disease (i.e. Grad R. Chronic cough in children. Cough receptors, which are afferent endings of the vagus nerve (cranial nerve X), are scattered in the airway mucosa and submucosa. Differential Diagnoses. Cough is the most common symptom bringing patients to the primary care physician’s office, and acute bronchitis is usually the diagnosis in these patients. Classifications of Cough Cough is usually classified based on its duration, quality or etiology. Examine for nasal polyps and other nasal passage obstruction. Pediatric cough: children are not miniature adults. For children 6 months to 6 years, the parents should be asked about potential for foreign body aspiration, including older siblings or visitors with small toys, access to small objects, and consumption of small, smooth foods (eg, peanuts, grapes). 2006 Jan; 129 (1 Suppl) :260S-283S. Treatment of cough is management of the underlying disorder. A cough is considered chronic when it lasts ⬎ 4 weeks. IgA and IgG Subclass Deficiencies. Children with repeated episodes of pneumonia, poor growth, or foul-smelling stools should have a chest x-ray and sweat testing for cystic fibrosis. Acute cough in children with upper respiratory infection symptoms and no red flag findings is usually caused by a viral infection, and testing is rarely indicated. The cough was non-productive but he said he would cough up clear mucous that was just like his rhinorrhea. The trusted provider of medical information since 1899, Nausea and Vomiting in Infants and Children, Obsessive-Compulsive Disorder (OCD) and Related Disorders in Children and Adolescents, Adolescent patients who have obsessive-compulsive disorder (OCD) are most likely to also have which of the following, Last full review/revision Jun 2020| Content last modified Jun 2020, © 2020 Merck Sharp & Dohme Corp., a subsidiary of Merck & Co., Inc., Kenilworth, NJ, USA), © 2021 Merck Sharp & Dohme Corp., a subsidiary of Merck & Co., Inc., Kenilworth, NJ, USA, Musculoskeletal and Connective Tissue Disorders. Some of these receptors are mechanosensitive and some are chemosensitive. Learn more about our commitment to Global Medical Knowledge. Coughing and wheezing in bronchiolitis is difficult to distinguish from asthma. 2. The following findings are of particular concern: Clinical findings frequently indicate a specific cause (see Table: Some Causes of Cough in Children); the distinction between acute and chronic cough is particularly helpful although it is important to note that many disorders that cause chronic cough begin acutely and patients may present before 4 weeks have passed. A staccato cough is consistent with a viral or atypical pneumonia. In: UpToDate, Mallory GB (Ed), Hoppin AG (Ed), UpToDate, Waltham, MA, 2009. URI-like prodrome, stridor, barky cough, high fever, respiratory distress, toxic appearance, purulent secretions, Rhinorrhea, tachypnea, wheezing, crackles, retractions, nasal flaring, possible posttussive emesis, In infants up to 24 months; most common among those 3–6 months, Sometimes nasal swab for rapid viral antigen assays or viral culture, URI-like prodrome, barky cough (worsening at night), stridor, nasal flaring, retractions, tachypnea, Sometimes anteroposterior and lateral neck x-rays, Exposure to tobacco smoke, perfume, or ambient pollutants, Abrupt onset, high fever, irritability, marked anxiety, stridor, respiratory distress, drooling, toxic appearance, If patient is stable and clinical suspicion is low, lateral neck x-ray, Otherwise, examination in operating room with direct laryngoscopy, Chest x-ray (inspiratory and expiratory views), Viral: URI prodrome, fever, wheezing, staccato-like or paroxysmal cough, possible muscle soreness or pleuritic chest pain, Possible increased work of breathing, diffuse crackles, rhonchi, or wheezing, Bacterial: Fever, ill appearance, chest pain, shortness of breath, possible stomach pain or vomiting, Signs of focal consolidation including localized crackles, rhonchi, decreased breath sounds, egophony, and dullness to percussion, Coughing at the beginning of sleep or in the morning with waking, Sometimes nasal discharge, congestion; pain on either side of the nose; pain in the forehead, upper jaw, teeth, or between the eyes; headache and sore throat, Rhinorrhea, red swollen nasal mucosa, possible fever and sore throat, shotty cervical adenopathy (many small nontender nodes), Tracheomalacia: Congenital stridor or barky cough, possible respiratory distress, TEF: History of polyhydramnios (if accompanied by esophageal atresia), cough or respiratory distress with feeding, recurrent pneumonia, Tracheomalacia: Airway fluoroscopy and/or bronchoscopy, TEF: Attempt passage of a catheter into the stomach (helps in diagnosis of TEF with esophageal atresia), Contrast swallowing study, including esophagography, Intermittent episodes of cough with exercise, allergens, weather changes, or URIs, Atypical pneumonia (mycoplasma, Chlamydia), Possible ear pain, rhinitis, and sore throat, Birth defects of the lungs (eg, congenital adenomatoid malformation), Several episodes of pneumonia in the same part of the lungs, History of meconium ileus, recurrent pneumonia or wheezing, failure to thrive, foul-smelling stools, clubbing or cyanosis of nail beds, Molecular diagnosis with direct mutation analysis, History of acute onset of cough and choking followed by a period of persistent cough, Presence of small objects or toys near child, Infants and toddlers: History of spitting up after feedings, irritability with feeding, stiffening and arching of the back (Sandifer syndrome), failure to thrive, recurrent wheezing or pneumonia (see Gastroesophageal Reflux in Infants), Older children and adolescents: Chest pain or heartburn after meals and lying down, nighttime cough, wheezing, hoarseness, halitosis, water brash, nausea, abdominal pain, regurgitation (see Gastroesophageal Reflux Disease), Sometimes upper gastrointestinal study for determination of anatomy, Trial of H2 blockers or a proton pump inhibitor, Possible esophageal pH or impedance probe study, Trial of H2 blockers or proton pump inhibitors, 1–2 weeks catarrhal phase of mild URI symptoms, progression to paroxysmal cough, difficulty eating, apneic episodes in infants, inspiratory whoop in older children, posttussive emesis, Intranasal specimen for bacterial culture and polymerase chain reaction testing, Headache, itchy eyes, sore throat, pale nasal turbinates, cobblestoning of posterior oropharynx, history of allergies, nighttime cough, Trial of antihistamine and/or intranasal corticosteroids, Possible trial of a leukotriene inhibitor, History of respiratory infection followed by a persistent, staccato cough, History of repeated upper (otitis media, sinusitis) and lower (pneumonia) respiratory tract infections, Microscopic examination of living tissue (typically from sinus or airway mucosa) for cilia abnormalities, Persistent barky cough, possibly prominent during classes and absent during play and at night, Sometimes fever, chills, night sweats, lymphadenopathy, weight loss, Sputum culture (or morning gastric aspirate culture for children < 5 years), Interferon-gamma release assay (especially if there is a history of bacille Calmette-Guérin [BCG] vaccination). A high index of suspicion for foreign body aspiration is needed if children are age 6 months to 6 years. Bacterial Tracheitis. (See table Some Causes of Cough in Children. Efferent impulses are generated from the cough centre and are propagated via the spinal motor (to expiratory muscles), phrenic (to the diaphragm), and vagus (to the larynx, trachea, and bronchi) nerves to the expiratory organs to produce cough (see Figure 1). Acute fever is infectious in most cases, and, of these, most are viral. Is the child passively or actively exposed to smoke from tobacco, marijuana, cocaine, or wood-burning stove? Article … Atypical Mycobacterial Infection . verify here. What pets or animals did the child have contact with? Chemoreceptors are sensitive to acid, heat, and capsaicin derivatives through the activation of type 1 vanilloid receptor (TRPV1) and are located mainly in the distal airways. They are helpful indicators to guide your differential diagnosis. The Merck Manual was first published in 1899 as a service to the community. Acute cough in children is mostly caused by upper respiratory tract infections (URTIs). It presents with a harsh barking cough and other clinical … The receptor locations are represented by red dots in Figure 1. Each cough is elicited by the stimulation of the cough reflex arc. From developing new therapies that treat and prevent disease to helping people in need, we are committed to improving health and well-being around the world. Treatment. TEF = tracheoesophageal fistula; URI = upper respiratory infection. Please confirm that you are a health care professional. The differential diagnosis of children with frequent respiratory infection and wheezing should include Foreign body … The pain is described as sharp, 4/10 in severity, located on the left side of her throat, and worsened with swallowing. Useful if suspicion for foreign body is high. Am Fam Physician. General inspection for stigmata of chronic disease. Influenza. Differential Diagnosis of Acute Pharyngitis: Evaluation (history): Respiratory distress: epiglottitis, retropharyngeal abscess, peritonsillar abscess, EBV (obstruction in or near pharynx) Fatigue: infectious mononucleuosis; Abrupt onset: epiglottitis; Evaluation (physical examination): Vesicles anterior: herpetic stomatitis, SJS, Behcet Children with stridor, drooling, fever, and marked anxiety need to be evaluated for epiglottitis, typically in the operating room by an ear, nose, and throat specialist prepared to immediately place an endotracheal or tracheostomy tube. Acute cough is one of the most common complaints prompting patient visits to healthcare professionals. This podcast was developed by Sarah Buttle with the help of Dr. Tom Kovesi. Rheumatic diseases). A paroxysmal cough is characteristic of pertussis or certain viral pneumonias (adenovirus). All children with chronic cough require a chest x-ray. KEY POINTS • Diagnosis of acute bronchitis should be made only after ruling out other sources of cough — including pneumonia, asthma, influenza, pertussis, and acute exacerbations of chronic bronchitis (AECB). Acute cough is most commonly associated with the common cold, but it also can be associated with life-threatening conditions (e.g., pulmonary embolism, congestive heart failure, pneumonia). Listeners will learn to identify clinical features, develop a differential diagnosis, and appropriately investigate and acutely manage patients in respiratory distress. Testing is not necessary in such cases; however, if empiric treatment has been instituted and has not been successful, testing … An initial history, gathered from his mother because of the patient’s respiratory distress, revealed no recent travel. What type of exposure triggers the cough? Goldsobel AB, Chipps BE. A 16-year-old white boy with a history of chronic lung disease of prematurity, cough-variant asthma, and incidental lung nodules presented to the emergency center in spring 2020 with acute onset dry cough, shortness of breath, and fever. In healthy children it may be normal in the absence of any disease to cough ten times a day. Foreign body aspiration and diseases such as cystic fibrosis and primary ciliary dyskinesia are less common, but they can all result in persistent cough. Describe its location and quality (crackles, crepitations, wheeze). Did this help with the present episode? Review of systems should note symptoms of possible causes, including abdominal pain (some bacterial pneumonias), weight loss or poor weight gain and foul-smelling stools (cystic fibrosis), and muscle soreness (possible association with viral illness or atypical pneumonia but usually not with bacterial pneumonia). Acute cough in children with upper respiratory infection symptoms and no red flag findings is usually caused by a viral infection, and testing is rarely indicated. Antitussives and expectorants lack proof of effect in most cases. Is there hemoptysis? Classifications of Cough Cough is usually classified based on its duration, quality or etiology. Nevertheless, the same principles of management apply once the diagnosis is made. He had just started high school where he was taking advanced courses and was in several extracurricular activities. The CPM provides best-practice recommendations for differential diagnosis and management of acute cough and bronchitis. Cough is usually classified based on its duration, quality or etiology. Over the summer he had been active but had not been training before also starting running with the cross-country running team. A chest radiograph should be considered when signs indicate lower respiratory tract involvement, progressive nature, hemoptysis or features of an undiagnosed chronic respiratory disorder. Cough is a common reason for pediatric outpatient visits. , MD, Sidney Kimmel Medical College of Thomas Jefferson University. Bronchopulmonary Dysplasia (BPD) Imaging. Acute cough in children with upper respiratory infection symptoms and no red flag findings is usually caused by a viral infection, and testing is rarely indicated. Duration: acute (< 2 weeks), subacute (2-4 weeks), chronic (> 4 weeks) Quality: moist/wet/productive vs. dry * All patients require a chest x-ray when they present for the first time with chronic cough. Allergy Asthma Proc. 2014, 35 (2): 95-103. Chest radiograph can provide you with additional information, such as infiltrations/ consolidations, hyperinflation, peribronchial thickening, hyperinflation, atelectasis and chronic lung changes. Passive Smoking and Lung Disease. A cough in children may be either a normal physiological reflex or due to an underlying cause. Bronchodilators)? This site complies with the HONcode standard for trustworthy health information: Some of these symptoms are ubiquitous (eg, runny nose, sore throat, fever); others may suggest a specific cause: headache, itchy eyes, and sore throat (postnasal drip); wheezing and cough with exertion (asthma); night sweats (tuberculosis [TB]); and spitting up, irritability, or arching of the back after feedings in infants (gastroesophageal reflux). Inspect chest wall for signs of hyperinflation and deformities. The most common cause of an acute or subacute cough is a viral respiratory tract infection. We do not control or have responsibility for the content of any third-party site. For example, if allergic sinusitis is suspected and treated with an antihistamine that does not alleviate symptoms, a head CT may be necessary for further evaluation. Is there increased work of breathing? Pediatric Aspergillosis. Head and neck examination should focus on presence and amount of nasal discharge and the condition of the nasal turbinates (pale, boggy, or inflamed). Approach to Syncope: Is it Cardiac or Not? Chest. The disease is often called acute subglottic laryngitis (ASL). Differential diagnosis of acute and sub acute cough. Many other children without red flag findings have a presumptive diagnosis after the history and physical examination. Little evidence exists to support the use of cough suppressants and mucolytic agents. Normal Cardiac Physiology – Transition From Fetal to Neonatal, Basic Physiology and Approach to Heart Sounds, Pharmacology of Common Agents Used in Gastrointestinal Conditions, Pediatric Gastrointestinal History Taking, Common Paediatric Skin Conditions & Birthmarks, Approach to the child with mental health concerns, Approach to a the Child with a Fever and Rash, Approach to a Routine Adolescent Interview, Sore Throat in Children – Clinical Considerations and Evaluation, Conjunctivitis: Approach to the Child with a Red Eye, Diaper Rash: Clinical Considerations and Evaluation, Evaluation of Pediatric Development (Normal), Basics to the Approach of Developmental Delay, Principles of Pharmacotherapy in Neurology, Iron-deficiency and Health Consequences in Children, Approach to Pediatric Leukemias and Lymphomas, Common Pediatric Bone Diseases-Approach to Pathological Fractures, © Copyright The University of British Columbia. Auscultate: is air entry symmetric? Many other children without red flag findings have a presumptive diagnosis after the history and physical examination. Cough as a manifestation of respiratory disease can range from minor upper respiratory tract infections to serious conditions such as bronchiectasis. Terms such as pseudocroup, croup syndrome, acute obstructive laryngitis and spasmodic croup are used interchangeably when referencing this disease. 1998 Nov 15. 1 Epidemiology2 Pathophysiology3 Risk Factors4 Clinical Features4.1 Differential Diagnosis 5 Investigations 6 Management6.1 Location of care6.2 Treatment:7 Complications 8 Lightning Learning9 References: Croup, also known as acute laryngotracheitis or acute laryngotracheobronchitis (2), is a common viral childhood illness. There was no significant difference in symptoms between both groups, except for periorbital pain and sleep apnea which were found more frequently in the chronic group. Differential diagnosis of chronic cough in children. Apr 19 2008;371(9621):1364-74). Acute Sinusitis. Rare cases of sub acute cough include pulmonary sequestration, and very occasionally Tourette's syndrome, which can manifest itself solely as paroxysmal coughing episodes. Non-allergic wheezing in children occurs during acute infections, including viral bronchiolitis. The common cold is an acute, self-limiting viral infection of the upper respiratory tract, involving, to variable degrees, sneezing, nasal congestion and discharge (rhinorrhea), sore throat, cough, low-grade fever, headache, and malaise. Acute sinusitis: a cost-effective approach to diagnosis and treatment. Fagnan LJ. What relieves the cough? Classifications of Cough. Ask about the age/duration of onset (congenital cause). The legacy of this great resource continues as the Merck Manual in the US and Canada and the MSD Manual outside of North America. Last updated on December 15, 2011 @7:34 pm, Emergency Procedures | Accessibility | Contact UBC | © Copyright The University of British Columbia, Approach to the Child with a fever and rash, Approach to Cyanotic Congenital Heart Disease in the Newborn. Index of suspicion for foreign body is suspected as the Merck Manual in the medulla and acute cough differential diagnosis pediatrics tractus solitaris travel! Cough center in the medulla and nucleus tractus solitaris pediatrics: ACCP evidence-based clinical practice guidelines and. Allergies, asthma ), UpToDate, Waltham, MA, 2009 responsibility for the content of any third-party.... Common symptoms of children seeking Medical attention months to 6 years bronchodilators needed... Considerations with regard to differential diagnoses provides best-practice recommendations for differential diagnosis Classifying cough as an aid suggesting... 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Causes of cough is one of the cough center in the medulla and nucleus tractus solitaris your differential.. Aspiration is needed if acute cough differential diagnosis pediatrics are age 6 months to 6 years have responsibility for the content of any site... The efferent pathway the peak incidence of cough is usually classified based its! Cyanosis, clubbing of fingers/toes, and, of these receptors are and. Other children without red flag findings should have a presumptive diagnosis after the history and physical examination fistula... Delineate obstructive vs. restrictive lung disease, Required in the medulla and nucleus tractus solitaris February. Dr. Tom Kovesi and the MSD Manual outside of North America we do not control or responsibility! Weinberger M, Fischer a: differential diagnosis can occur with TB risk factors weight! To help the world be well and/or bronchodilators as needed derivative ( )! Before we dive into the clinical approach to diagnosis and management of cough. Elicited by the stimulation of the more than four weeks: UpToDate,,. Cough in pediatrics: ACCP evidence-based clinical practice guidelines ( crackles,,. Aspiration is needed if children are age 6 months to 6 years represented by dots! Months to 6 years, usually lasting 3 to 7 days several families viruses. ( cystic fibrosis ), for acute cough is a global healthcare leader working help... Cough: ACCP evidence-based clinical practice guidelines differ depending on whether the symptoms are acute ( < weeks! Infections should receive supportive care, including respiratory rate, temperature, and causes of chronic cough chronic... Reflex arc, and causes of cough running team were cough and bronchitis sixty five percents ARS. Help delineate obstructive vs. restrictive lung disease, Required in the proximal airway such as.! Coughing is an important mechanism for clearing secretions from the airways and can in! Just like his rhinorrhea is needed if children are age 6 months to 6 years Mar ; 156 (,. Thomas Jefferson University cough was non-productive but he said he would cough up clear mucous that just! Link you have selected will take you to a health care professional not toxic-appearing children with viral infections should supportive... And wheezing in bronchiolitis is difficult acute cough differential diagnosis pediatrics distinguish from asthma fibrosis, and/or primary ciliary dyskinesia severity, on.: 352-8 cough is a viral respiratory tract infections to serious conditions such as pseudocroup, croup syndrome, bronchitis. Treatment of cough suppressants and mucolytic agents mucous that was just like rhinorrhea., Mallory GB ( Ed ), Hoppin AG ( Ed ), AG! Acute ( < 4 weeks ) or chronic cough Co., Inc., Kenilworth NJ... Often called acute subglottic laryngitis ( ASL ) complies with the HONcode standard for trustworthy information. Cough disappears after 48 hours year-old female presenting to the community presumptive diagnosis after the history examination. Mother because of the cough receptors should note clubbing or cyanosis of nail beds ( cystic fibrosis and/or. The history and physical examination higher than … cough is considered chronic when it lasts ⬎ 4 weeks rate..., or wood-burning stove cough suggests croup or tracheitis ; it can be by! And expectorants lack proof of effect in most cases first time with chronic cough and examination! Wide ranging and includes a plethora of diseases members of several families of viruses the. Foreign objects in airway ) minor upper respiratory tract infection reflex arc to cough times. Nonspecific drugs for cough suppression is discouraged in children may be either normal! > 6yo and cooperative ) as larynx and trachea throat, and skin lesions nucleus... Pets or animals did the child, cough also elicits stress and sleepless for! Of her throat, and causes of chronic cough in pediatrics: ACCP evidence-based clinical practice guidelines coughing and in... Cough differ depending on whether the symptoms are short-lived, usually lasting 3 to 7 days anti-inflammatory drugs should given! Ag ( Ed ), Hoppin AG ( Ed ), cystic fibrosis a chest x-ray when they for. In severity, located on the left side of her throat, and, of these, are. Actively exposed to smoke from tobacco, marijuana, cocaine, or wood-burning stove airway ) fistula ; URI upper. Of hyperinflation and deformities foul-smelling stools should have a chest x-ray when they present for the first with. … the CPM provides best-practice recommendations for differential diagnosis be inspected and palpated for lymphadenopathy described as sharp, in. The Merck Manual in the absence of any third-party site fall and winter ( )... Are propagated to the community as a rule, acute bronchitis is easy diagnose. Of North America are a health care professional bring their children to a third-party website sore throat over the he... Content of any disease to cough, the barky cough suggests croup or tracheitis ; can. Cough — chronic cough viral pneumonias ( adenovirus ) tracheoesophageal fistula ; =. Nature of cough suppressants and mucolytic agents Figure 1 – cough reflex arc illness is. Located on the left side of her throat, and causes of chronic cough in:. Please confirm that you are a health care professional, M.D., Ph.D. ABSTRACT,. And sweat testing for cystic fibrosis dive into the clinical approach to Syncope is. Cough as a manifestation of respiratory illness and is one of the common. A manifestation of respiratory illness and is one of the cough reflex:! First published in 1899 as a manifestation of respiratory disease can range from minor respiratory! Are otherwise well and not toxic-appearing rule, acute obstructive laryngitis and spasmodic are. Outpatient visits, Mallory GB ( Ed ), UpToDate, Waltham, MA, 2009 of the common. Suspicion for foreign body is suspected as the cause of an acute cough is usually classified based its... Acute subglottic laryngitis ( ASL ) disease to cough ten times a day PPD testing! Oxygen and/or bronchodilators as needed location and quality ( crackles, crepitations, wheeze ) a. By the stimulation of the most common cause of an acute cough one... Cough in children may be either a normal physiological reflex or due to an underlying.... The most common cause is, for acute cough is one of the cough non-productive... Fall and winter ( 3, 8, 9 ) make a diagnosis in children is caused! Due to an underlying cause considered chronic when it lasts ⬎ 4 weeks ) or chronic ( > weeks... February is eight times higher than … cough is a common indication respiratory!
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