Diagnosing ARIs Series

Acute cough in children

Graham Worrall

MBBS MSc FCFP

ecause acute cough has a different range of causes

in children younger than 15 years of age than it
does in adults, children should be assessed and treated
differently. 1 In general, there are fewer randomized
controlled trials in children than in adults, so the evidence is less bountiful, and an important aspect of
treating children is paying attention to parental concerns and expectations.
One Tuesday morning in the clinic, Mrs Jones brings her
4-year-old daughter, Jenny, in to see you. Jenny has had
a cough for about 4 days; she might have been feverish
at the beginning of the illness, but she is not feverish
now. She has a runny nose, and Mrs Jones says she was
pulling at her ears yesterday. Her cough sounded dry
and barky; she was not short of breath and her colour
was always normal. Jenny has been at home for 3 days,
missing day care. Jennys medical record shows that
at the age of 3 months, she was hospitalized for treatment of bronchiolitis. She has twice been treated for
otitis media and has received hydrocortisone cream for
infantile eczema. Mrs Jones says that when they were
away on holiday 2 years ago, a GP in another town
gave Jenny antibiotics for pneumonia. Jenny has had no
other hospital admissions or surgical procedures.

Epidemiology and population at risk

Cough is the most common pediatric problem managed by FPs, and it is more common in preschool children than in older children.2 Two out of 3 children aged
between 0 and 4 years visit their FPs at least once a
year with acute respiratory infections, and up to threequarters of them will have coughs. 3,4 Most coughs
are caused by acute viral infections, and 7% to 12% of
coughs are due to asthma; all other causes are rare.5 In
Australia 11.4% of child coughs were due to asthma, and
only 1.2% were caused by pneumonia6; in Dutch general
practice, only 1.9% of coughs were due to pneumonia.7
With the exception of 0.3% due to whooping cough, all
other coughs were the result of acute viral infections.
Most coughs in children are caused by undifferentiated
acute respiratory tract infectionsa cough that does
not conform to any clear diagnostic syndrome such as
croup, whooping cough, pneumonia, or bronchiolitis.8
As with adults, childrens cough, whether described
as a symptom of upper respiratory tract infection or

This article has been peer reviewed.

Cet article a fait lobjet dune rvision par des pairs.
Can Fam Physician 2011;57:315-8

acute bronchitis, is the most frequently managed

acute presentation in primary care. These 2 diagnoses
represent at least 75% of all coughs seen. Of the other
causes, asthma is the most common; other, potentially
dangerous, causes are much less common (Figure 1).3
As Jenny is an otherwise healthy child and is not taking
any respiratory medicines, it is probable that her cough
is due to an acute viral infection, probably picked up
in the day-care centre; her mothers description of a
barky cough makes you wonder whether she might
have croup.
Before you examine her, you consider what else it
could be.

What else could it be?

Figure 13 shows that, overwhelmingly, acute coughs in
children are due to acute viral infections (common colds,
acute bronchitis, croup, and influenza). Although there
is usually no need to be concerned with the chronic respiratory and cardiac conditions that affect some adults,
acute cough can be indicative of conditions that the
physician should not miss, such as asthma, bronchiolitis,
whooping cough, pneumonia, and foreign body aspiration. A brief focused history will usually give information
about such conditions.
Alarm symptoms. If there were an epidemic at the
day-care centre, Mrs Jones would have been informed.
Jennys immunization record will influence the
chances of whooping cough or Haemophilus influenzae infection. A sudden history of choking will point
to aspiration of a foreign body or exposure to toxic
irritants. Mrs Jones should know if Jenny has been
exposed to any irritants. What time of year is it? Peak
incidence of infective cough is January to March; epidemics of croup tend to occur in autumn and bronchiolitis in winter.
Alarm signs. The child will look ill (with pneumonia
or influenza) or be short of breath with tachypnea (with
asthma or foreign body aspiration). The child will be
working hard to breathe, perhaps with chest retractions.
There might be a high fever (with pneumonia, but some
children can run sudden high fevers with otherwise
innocuous viral infections).

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Diagnosing ARIs Series

Figure 1. Distribution of causes of acute cough among children in typical general practice
1%

Common cold

1%

Bronchitis or bronchiolitis

1%

Asthma

5%

Whooping cough

8%

Croup
Influenza

5%

Pneumonia

2%

Foreign body
Irritants (tobacco smoke)

9%

GERD

59%
9%

GERDgastroesophageal reflux disease.

Data from McCormick et al.3

Jenny looks quite well to you. She is not running a

fever and she is not short of breath. Her respiratory
rate is 20 breaths/min; her pulse is 96 beats/min;
and her temperature is 37.4C. She has a runny nose,
but her ears and throat are unremarkable. Her chest
is clear. During the 15 minutes she is in your office,
she coughs only once; the cough is dry and barky,
but not spasmodic; the child barely seems to notice
it, although Mrs Jones jumps. No alarm symptoms or
signs are present.
Mrs Jones says Jenny has received pertussis,
Haemophilus, and influenza vaccines, according to the
schedules. Jenny is too old to have bronchiolitis. Mrs
Jones admits to smoking 15 cigarettes per day at home.
You make a presumptive diagnosis of mild croup, following a viral upper respiratory tract infection, which is
now recovering.

How sure of the diagnosis are you?

Most childhood respiratory tract infections are diagnosed based on history and examination alone. This is
true for croup, which is associated with the same microorganisms as the common cold. The barking cough of
croup and the paroxysms of whooping cough are classic and easy to recognize,9 as is the wheeze in infants
with bronchiolitis. Knowledge of the childs vaccination
status can help; clearly whooping cough and influenza
are less common in children who have been immunized
against these illnesses.

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Much about the diagnosis of acute bronchitis in children is uncertain. A chart review of children in the United
States with cough showed that GPs were more likely to
diagnose acute bronchitis if there was sputum production
(odds ratio [OR]=25), rales or rhonchi on examination
(OR=12), or a past history of lower respiratory tract infection (OR=3); the presence of fever and the duration of illness were not associated with the diagnosis.10
Unfortunately, there is little good quantitative evidence that will enable practitioners to estimate the likelihood of serious illness, in numerical ways, as there is
for adults with acute cough.
Both doctors and parents worry that a coughing child
might have pneumonia. Several studies have developed
ways to rule out pneumonia: in the absence of tachypnea and chest retractions,11 if the respiratory rate is
normal, auscultation is clear, and the child is not working hard to breathe, findings from chest radiographs are
unlikely to be positive for pneumonia.12
If you are worried that the child might get sicker,
you can teach the parents to observe for fast breathing,
chest retractions, and wheezing as danger signs.13
You have decided that there are no symptoms or signs that
point to a serious respiratory illness and you decide that Jenny
can be safely treated at home. You advise Mrs Jones of this,
and that a chest x-ray scan is not needed. You tell Mrs Jones
that complete and speedy recovery is to be expected, but that
a small proportion of children develop complications.

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Diagnosing ARIs Series

Is it likely to get worse?
Up to 12% of children with cough experience complications,14 and although the complications are usually
mild and easily treated, some children do become very
sick. Otitis media is the most common complication, followed by rash, diarrhea, and vomiting; only 5% of cases
progress to bronchitis or pneumonia. Unfortunately,
there is a paucity of information regarding the predictive value of signs and symptoms in children with cough.
The only study in primary care that looks at this is
British15; only the presence of fever and chest signs were
independently associated with complications (although
presence of asthma and tachypnea initially produced
high ORs, their 95% confidence intervals crossed 1.0).
While children with neither fever nor chest signs had a
posttest probability of complications of only 6%, for children with chest signs it was 18%, with fever it was 28%,
and when both fever and chest signs were present the
posttest probability was 40% (Table 1).15
Croup is a self-limiting illness. Only about 4% of children with croup need to be hospitalized, and only 1
in 4500 children with croup gets ill enough to require
intubation.16

Table 1. Odds ratios for predicting complications after

acute childhood cough
SIGNS AND SYMPTOMS

Added chest signs

POSITIVE ODDS RATIO

2.78

NEGATIVE ODDS
RATIO

1.0

Fever

4.65

1.0

Tachypnea

3.80

1.0

Attends day care

1.0

NA

Illness severity

1.34

NA

Lives with smoker

1.0

NA

Social deprivation

1.0

NA

Known to have asthma

2.90

NA

NAnot applicable.
Data from Hay et al.15

You tell Mrs Jones that the cough might be gone in a

week, but that it would not be unusual for it to last for 2
to 3 weeks longer.

What does the parent expect?

As an FP you will also rely on your knowledge of the
mothers consulting patterns for the childs past illnesses. A British study 18 of mothers who consulted
their FPs because their children had been coughing
found that one of the main concerns mothers had was
that their children were going to die because of choking on phlegm or vomit; they were also worried about
asthma and crib death. Some mothers also worried that
their children would develop long-term chest damage.
Mothers themselves had been affected by sleep deprivation because of their worries about their children.
First-time mothers and mothers with lower levels of
education are more likely to consult their physicians.19
Several studies have found that if the parent expects
to receive an antibiotic prescription, or the physician believes that the parent expects one, there is an
increased likelihood that such a prescription will be
written; this effect is second only to the presence of
added respiratory sounds as a predictor of antibiotic prescription.20 On the other hand, if the parent thinks the
child has a viral respiratory tract infection, the child is
only half as likely to receive antibiotics.
You ask Mrs Jones what she was expecting would be the
diagnosis and treatment for Jennys cough.
She says she was worried that Jenny might be
developing pneumonia again; she is very relieved to
hear that there is no sign of this. She understands that
croupy coughs usually sound worse than they really are,
and that a 4-year-old is in no real danger. She doesnt
really know what the treatment for croup is, but she
remembers Jenny has taken antibiotics 3 times before.

Deciding on the best treatment

You tell Mrs Jones that it is very unlikely that Jenny will
get worse or have any complications. If Jenny does get
worse, she can come back to see you without making
an appointment.

How long will the cough last?

Most children with croup are only mildly ill, and their
croupy symptoms resolve within 48 hours. The cough
might persist, however. Both clinicians and parents tend
to underestimate how long acute cough in children will
take to completely resolve. Prospective cohort studies
have found that not until 10 days after onset have 50%
of children with coughs recovered, and 10% of children
are still coughing at 25 days.17

Evidence-based guidelines have shown that there are no

effective medications to either cure or relieve the symptoms of acute cough in children.1,9 Once the FP has confidently excluded the rarer and more serious conditions
for which therapy is effective, explanation is required for
the parent.
Antibiotics have no effect on viral infections; indeed
they might cause side effects that are more distressing
than the cough. Most parents will not be too concerned
about increasing antibiotic resistance; however, most
should be told that antibiotics are at least as likely to
cause side effects as they are to produce improvement
in their children. They should also be told that serious
adverse events and accidental poisonings have been
recorded in children from exposures to over-the-counter
medications.21

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Diagnosing ARIs Series

There is good evidence that oral corticosteroids are
an effective treatment for moderate to severe croup22,23;
they reduce symptom severity, illness duration, and
return visits to the doctor. Unfortunately, all the corticosteroid trials have been done in hospital wards or
childrens hospital emergency departments; it is not
certain whether steroids would be of clinically significant benefit for the milder types of croup seen and
managed entirely by GPs.

2. Morrell DC. Symptom interpretation in general practice. J R Coll Gen Pract

1972;22(118):297-309.
3. McCormick A, Fleming D, Charlton J. Morbidity statistics from general practicefourth National Morbidity Survey, 1991-92. London, UK: HMSO, Office for
National Statistics; 1995.
4. Hope-Simpson RE, Miller DL. The definition of acute respiratory illnesses in
general practice. Postgrad Med J 1973;49(577):763-70.
5. Ayres JG, Noah ND, Fleming DM. Incidence of episodes of acute asthma and
acute bronchitis in general practice 1976-87. Br J Gen Pract 1993;43(374):361-4.
6. Meza RA, Bridges-Webb C, Sayer GP, Miles DA, Traynor V, Neary S. The
management of acute bronchitis in general practice: results from the
Australian Morbidity and Treatment Survey, 1990-1991. Aust Fam Physician
1994;23(8):1550-3.

Mrs Jones accepts your explanation that an antibiotic is

7. Verheij TJ, Kaptein AA, Mulder JD. Acue bronchitis: aetiology, symptoms and
treatment. Fam Pract 1989;6(1):66-9.

not needed for self-limiting croup. She understands that

8. Davy T, Dick PT, Munk P. Self-reported prescribing of antibiotics for children

it is too late in the illness for steroid therapy. She men-

with undifferentiated acute respiratory tract infections with cough. Pediatr

tions that she has already been giving Jenny a childrens

cough syrup twice a day and at bedtime. You explain
that the cough syrup is probably having no effect; she
agrees that it doesnt seem to be working. You mention
that her second-hand smoke might be exacerbating the
cough; she agrees to smoke outside while Jenny is ill.

Infect Dis J 1998;17(6):457-62.

9. Chang AB, Landau LI, Van Asperen PP, Glascow NJ, Robertson CF, Marchant
JM, et al. Cough in children: definitions and clinical evaluation. Med J Aust
2006;184(8):398-403.
10. Vinson DC. Acute bronchitis in children: a clinical definition. Fam Pract Res
J 1991;11(1):75-81.
11. Shamoon H, Hawamdah A, Haddadin R, Jmeian S. Detection of pneumonia
among children under six years by clinical examination. East Mediterr Health
J 2004;10(4-5):482-7.

When should I bring my child back?

12. Margolis P, Gadomski A. The rational clinical examination. Does this child

There is little need for most children with acute cough to

be seen more than once. However, FPs know that some
parents will need to be seen for further reassurance.
Most parents will need to be told to return if the cough
does not improve in a certain time (which is longer
than most parents think). All parents should be told, or
should understand, that they can come back any time if
they observe or fear their children are getting worse.

13. Gadomski AM, Aref GH, Hassanian F, el Ghandour S, el-Mougi M, Harrison

You tell Mrs Jones that Jenny will almost certainly con-

17. Hay AD, Wilson A, Fahey T, Peters TJ. The duration of acute cough in pre-

have pneumonia? JAMA 1998;279(4):308-13.

tinue to get better. Knowing her anxieties, you agree to

check Jenny again in 3 days to judge whether she is fit
enough to resume day care.

LH, et al. Caretaker recognition of respiratory signs in children: correlation

with physical examination signs, x-ray diagnosis and pulse oximetry. Int J
Epidemiol 1993;22(6):1166-73.
14. Hay AD, Wilson AD. The natural history of acute cough in children aged 0 to 4
years in primary care: a systematic review. Br J Gen Pract 2002;52(478):401-9.
15. Hay AD, Fahey T, Peters TJ, Wilson A. Predicting complications from acute
cough in pre-school children in primary care: a prospective cohort study. Br J
Gen Pract 2004;54(498):9-14.
16. Marx A, Trk TJ, Holman RC, Clarke MJ, Anderson LJ. Pediatric hospitalization for croup (laryngotracheobronchitis): biennial increases with human
parainfluenza virus 1 epidemics. J Infect Dis 1997;176(6):1423-7.
school children: a prospective cohort study. Fam Pract 2003;20(6):696-705.
18. Cornford CS, Morgan M, Ridsdale L. Why do mothers consult when their
children cough? Fam Pract 1993;10(2):193-6.
19. Dewey CR, Hawkins NS. The relationship between the treatment of cough
during early infancy and the maternal education level, age and number of

Dr Worrall is Honorary Research Professor in the Department of Family

Medicine at Memorial University of Newfoundland in St Johns.
Competing interests
None declared

dren with cough: a report from ASPN. J Fam Pract 1993;37(1):23-7.

References
1. Irwin RS, Baumann MH, Bolser DC, Boulet LP, Braman SS, Brightling CE,
et al. Diagnosis and management of cough executive summary: ACCP
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Canadian Family Physician Le Mdecin de famille canadien

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20. Vinson DC, Lutz LJ. The effect of parental expectations on treatment of chil21. Gunn VL, Taha SH, Liebelt EL, Serwint JR. Toxicity of over-the-counter

Correspondence
Dr Graham Worrall, Dr W.H. Newhook Memorial Clinic, Family Medicine, Box
449, Whitbourne, NF A0B 3K0; e-mail gworrall@[Link]

318

other children in the household. ALSPAC Study Team. Avon Longitudinal

cough and cold medicines. Pediatrics 2001;108(3):E52.

22. Kairys SW, Olmstead EM, OConnor GT. Steroid treatment of laryngotracheitis: a meta-analysis of the evidence from randomised trials.
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23. Ausejo M, Saentz A, Pham B, Moher D, Chalmers TC, Kellner JD, et al. The
effectiveness of glucocorticoids in treating croup: a meta analysis. West J Med
1999;171(4):227-32.

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