Clinical Investigations from the RACP PEER REVIEWED ARTICLE CPD 1 POINT

Investigating the
child with a cough
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Each month we present authoritative advice on the investigation of a common clinical

problem, specially commissioned for family doctors by the Board of Continuing Medical
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Education of the Royal Australasian College of Physicians.

Children who present with recurrent episodes of regard coughing for more that two weeks as
wheeze, cough and breathlessness usually have meeting the criterion for a prolonged cough.
asthma and cause no diagnostic dilemma for Table 1 lists the more important causes of a pro-
GPs. In the
Downloaded last 30use
for personal years,
only. Nomuch continuing
other uses med-permission.
permitted without longed cough. 2008.
© MedicineToday
ical education has been directed towards the Acute bronchitis is an acute febrile illness
diagnosis and management of childhood asthma. in which cough is the predominant sign. The
This is appropriate given the morbidity of this maximum concentration of cough receptors in
condition; however, there has been a tendency to the airways is in the larynx, trachea and bronchi.
believe that asthma is the only important respira- Many children whose respiratory illness is labelled
tory problem
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for personal use only. NoThis
other article focuses
uses permitted without as an©upper
onpermission. respiratory
MedicineToday 2007. tract infection have
a different group of children, those who have cough as a prominent feature. These children have
cough without wheeze. Most of these children do inflammation in the larynx, trachea or bronchial
RICHARD L. HENRY not have asthma and will not respond to asthma tree. Some people believe that postnasal drip or
MB, BS, MD, FRACP, DipClinEpi
medications. other upper respiratory tract secretions stimulate
For convenience, the main situations consid- cough receptors in the larynx – this view is not
Professor Henry is Professor of Downloaded for personal
ered in this [Link]
No otherlasting
uses permitted without
at least twopermission.
held © byMedicineToday 2006.
most respiratory paediatricians.
Paediatrics, School of Women’s weeks and recurrent episodes of cough without The cough in viral bronchitis may be dry or
and Children’s Health, wheeze. Both these clinical scenarios are com- loose. When the cough is loose, in most cases the
University of New South Wales, mon in general practice. Establishing an exact sputum is swallowed rather than being expecto-
and Respiratory Paediatrician, diagnosis is often difficult and management rated. If wheeze is associated with a viral respira-
Sydney Children’s Hospital, options are limited. tory infection, asthma is the likely diagnosis. The
Randwick, NSW. Downloaded for personal use only. No other uses permitted without permission.
absence © MedicineToday
of [Link] asthma unlikely. The
Prolonged cough cough in viral bronchitis usually resolves after one
Series Editor Causes to two weeks but may last longer. If it does, the
CHRISTOPHER S. The definition of prolonged cough is somewhat possibility of complications, such as segmental col-
POKORNY arbitrary. Most parents and doctors would lapse or bacterial infection, should be considered.
MB BS, FRACP
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IN SUMMARY

Dr Pokorny is Honorary •
Viral bronchitis is a common cause of cough.
Secretary, Board of Continuing •
Whooping cough should be considered in a child with prolonged cough.
Medical Education, Royal •
Cough without wheeze is usually not asthma.
Australasian College of •
Chest x-ray is the first investigation to consider in the child with prolonged or
Physicians, and a recurrent cough.
Downloaded•for CT
personal
scan useofonly.
theNochest
other uses permitted
is the without permission.
investigation of choice© MedicineToday 2003.
for bronchiectasis.
Gastroenterologist in private
practice, Sydney, NSW. • A thorough history is of more value than most available investigations.

54 MedicineToday ❙ November 2002, Volume 3, Number 11

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 Whooping cough remains a significant cause
of prolonged cough. The typical illness begins with
a runny nose and cough. The cough becomes
progressively worse and is paroxysmal in nature.
The child may cough until his or her face is red
and then becomes cyanosed. Post-tussive vomiting
is a feature, and the coughing may cause
Downloaded subcon-
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junctival haemorrhage (Figure). Although the
textbook description is that the coughing spasms
end with the whoop that gives the disease its
name, a whoop is often absent. Furthermore,
immunisation against pertussis doesfornot
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complete protection. In both immunised and
nonimmunised children, the most common
cause of a paroxysmal cough lasting one to three
months is pertussis. Between paroxysms the
child is well. If exhausted and concerned parents Figure. Subconjunctival haemorrhages in a girl with whooping cough.
present with a story that their completely
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looking child has had a terrible cough for weeks,
whooping cough must be considered. Table 1. Causes of prolonged cough
Mycoplasma pneumoniae infection is a frequent
cause of bronchitis and pneumonia, particularly Viral bronchitis
in school-aged children. Most children are not par- Bacterial bronchitis
ticularly unwell and often present a for
Downloaded week or two
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other uses permitted
after the onset of fever and cough. Headache, Mycoplasma infection
malaise, sore throat, runny nose and other con- Tuberculosis
stitutional symptoms may be present. Foreign body
Tuberculosis is rare but an important consider-
ation in migrant and indigenous children, partic-
ularly when there has been Downloaded
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associated
with cough. Table 2. Causes of recurrent cough
Foreign body inhalation needs to be remem-
bered as a possible cause, especially in younger Recurrent acute bronchitis
children. Irritative bronchitis (passive smoking)
Recurrent croup
Investigations other uses permitted without permission. © MedicineToday 2005.
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An abnormal chest x-ray may, according to the – cystic fibrosis
clinical picture, support a diagnosis of Myco - – post-infections
plasma infection or suggest the need to consider – immunodeficiency
a foreign body or tuberculosis. – other causes
Clinical suspicion is the most important Aspiration
investigation for whooping Downloaded
[Link]
markeduse only. No other
– uses reflux © MedicineToday 2004.
permitted without permission.
gastro-oesophageal
lymphocytosis may be present. Unfortunately, – dyscoordinate swallowing
very few laboratories find it easy to culture Bor- – H-type tracheo-oesophageal fistula
detella pertussis, and an elevated serum IgA to Focal lesions
pertussis may clinch the diagnosis. – tracheomalacia
For Mycoplasma infection, the definitive test Psychogenic
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is specific IgM. Asthma
A Mantoux test is used to detect tuberculosis. Postnasal drip (controversial)

MedicineToday ❙ November 2002, Volume 3, Number 11 55

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The child with a cough
continued

Recurrent cough cough will have been present from early • incompletely resolved lower
Causes in life. respiratory tract infection
There is some overlap in the causes of Loose cough every day is the hallmark • recurrent aspiration
recurrent cough and the causes of pro- of bronchiectasis. One of the causes of • retained foreign body
longed cough. Table 2 lists some of the bronchiectasis, cystic fibrosis, may be • immunodeficiency
causes of recurrent cough. missed on newborn screening testing. • immotile cilia syndrome.
Although it is importantDownloaded
to try tofordis-
personalOther
use [Link]
No otherofuses
bronchiectasis
permitted without include: If your2010.
permission. © MedicineToday secretary tells you that there
tinguish children who have recurrent
episodes of cough and who are well
between episodes from those who have a
persistent daily cough, many parents
find this a surprisingly difficult distinction
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to make. Similarly, it may be difficult for
parents to distinguish a daily productive
cough, which suggests suppurative lung
disease (bronchiectasis), from a dry
cough, which is associated with croup or
tracheomalacia or may be Downloaded
psychogenic.
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Asking the child to cough may prove
very helpful.
Recurrent episodes of cough without
wheeze, especially in association with
coryzal symptoms, are characteristic of
recurrent acute bronchitis. Downloaded
In some cases
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there may be no obvious evidence of
acute infection. An infective bronchitis
may indeed be the cause, but this also
raises the possibility of:
• recurrent aspiration, secondary to
gastro-oesophageal reflux, Downloaded for personal use only. No other uses permitted without permission. © MedicineToday 2006.
dyscoordinate swallowing, or a
combination of the two (in rare cases,
an H-type tracheo-oesophageal fistula
is the cause of aspiration)
• irritative bronchitis, secondary to the
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effects of parental smoking.
A barking cough, usually with inspira-
tory stridor, suggests croup. Recurrent
episodes of viral croup are usually obvious.
Less well recognised is spasmodic croup.
The characteristic feature of this is a child
who goes to bed completely Downloaded
well for
andpersonal use only. No other uses permitted without permission. © MedicineToday 2004.
wakes up in the middle of the night with a
barking cough and stridor. The absence
of prodromal viral symptoms often leads
to the erroneous belief that this could not
be croup.
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The child with tracheomalacia may
also have a barking cough, associated
with stridor and wheeze. In this case the

56 MedicineToday ❙ November 2002, Vol 3, No 11

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is a child in the waiting room with a ter- present, asthma is possible but unlikely. the chest will often reveal abnormalities
rible cough, the diagnosis is likely to be that are not apparent on x-ray.
pyschogenic. The cough has a honking Investigations CT scanning in children requires par-
quality, rather like the sound of a goose. A chest x-ray is the initial investigation ticular expertise and in young children a
The diagnosis of asthma always needs in the child with persistent loose cough. general anaesthetic, so it is wise to seek a
to be considered in the child with recur- Unfortunately, a normal x-ray does not consultant paediatric opinion before this
rent cough. If wheeze hasDownloaded
never been
for personalexclude bronchiectasis
use only. No andwithout
other uses permitted a CTpermission.
scan of© MedicineToday
test is undertaken.
2010.
Sweat testing for cystic fibrosis requires
a specialised biochemistry service that
performs the test regularly, to avoid the
risk of false-positive and false-negative
results. 2009.
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Older children (from about 6 years)
will be able to perform simple spirometry
before and after bronchodilators. The
presence of airways obstruction that per-
sists after bronchodilators supports a
diagnosis2008.
Downloaded for personal use only. No other uses permitted without permission. © MedicineToday of bronchiectasis and is an
absolute indication for referral.
The possibility of lung disease sec-
ondary to reflux is difficult to prove or
exclude. Even if reflux is present, we need
to distinguish a casual from a causal
association.
Downloaded for personal use only. No other uses permitted without permission. © MedicineToday A history of cough related to
2007.
feeding is suggestive of a causal association.
Barium swallow is of limited value. A
24-hour oesophageal pH study where
the parents document cough (so that one
can look for a correlation between falls in
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oesophageal [Link] and onset of cough) is
likely to be more helpful but requires
admission to hospital. Often a trial of
anti-reflux therapy is the diagnostic
investigation that is chosen.
Bronchoscopy is indicated if there is
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suspicion 2005.
of an anatomical abnormality
(such as tracheomalacia) or a foreign
body, and it may be helpful in addition
to a CT scan of the chest in assessing
bronchiectasis.

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Summary2004.
Children with recurrent cough and pro-
longed cough often present a diagnostic
challenge. A thorough history is of more
value than most available investigations.
Chest x-ray, lung function and other spe-
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cific investigations all have a role, but their
use needs to be guided by the patient’s
clinical features. MT

MedicineToday ❙ November 2002, Vol 3, No 11 57

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