on line editionCough in children Professional artiCle id 1 Unit of Pulmonary Diseases, Division of Paediatrics, University Medical Centre Ljubljana, Ljubljana 2 Community health centre Ormož, Ormož 3 Franc Derganc General Hospital of Nova Gorica, Šempeter pri Gorici Correspondence: Marina Praprotnik, e: marina.praprotnik@ kclj.si Key words: acute cough; subacute cough; chronic cough; child; management Cite as: Zdrav Vestn. 2017; 86:212–25. received: 29. 7. 2016 accepted: 27. 3. 2017 Cardiovascular systemProfessional article Zdrav Vestn | Maj – June 2017 | Volume 86 Cough in children Marina Praprotnik,1 Melanija Zupanić,2 tina lozej,3 Uroš Krivec,1 Working group for pediatric pulmonology Abstract Cough is a common problem in children. Acute cough lasts less than 3 weeks, subacute 3–8 weeks and chronic cough more than 8 weeks. Acute cough is usually caused by common viral upper respiratory tract infection. However, a child should be thoroughly evaluated to rule out a serious underlying condition or disease responsible for the cough. The commonest cause of subacute cough is viral infection (postinfectious cough) and it usually re- solves spontaneously. If the child is otherwise healthy and the cough is dry and there are no specific alerts for a serious disease and the cough is resolving, a period of observation is all that is recom- mended. If there are any specific pointers in the child’s history and examination identified for in- haled foreign body, chronic lung disease or in a case of progressive cough immediate investigations are needed. Most chronic coughs in childhood are due to viral respiratory infections, but may signify a serious underlying disease too. Chronic cough is subdivided into specific cough (i.e. cough associated with other symptoms and signs suggestive of an associated or underlying problem) and nonspecific cough (i.e. dry cough in the absence of an identifiable respiratory disease of known etiology). To prevent unnecessary investigations and ineffective treatment and at the same time not to overlook a severe underlying disease cough guidelines have been designed which are based on evidence-based medicine. Cite as: Zdrav Vestn. 2017; 86:212–25. 1. Introduction A cough in children is one of the most common presenting symptoms to pediatricians. It can be very distressing for children and parents as it interferes with sleep, ability to play and school per- formance (1). A cough is the most important de- fensive reflex that enhances clearance of secretions from the airways. Cough receptors are found on the surface cells that line the upper respiratory tract from larynx to segmental bronchioles and are irritated by chemical and mechanical stimuli. During childhood, the respiratory tract and nervous system undergo a se- ries of anatomical and physiological maturation processes, which make the cough center in children more sensi- tive to some stimuli from the environ- ment (2). on line edition Zdrav Vestn | Maj – June 2017 | Volume 86 CardioVasCUlar systeM Figure 1: acute cough algorithm. Possible underlying etiologies of cough range from common cold to se- rious causes such as cystic fibrosis (CF), tumor and foreign body aspiration. An attempt should be made to find the underlying cause of cough and then apply specific treatment. ???Of the un- derlying cause. Cough can be classified by different criteria such as the underlying cause, time of onset and characteristics (pro- ductive, dry). From the practical point of view the classification based on the duration of cough is mostly used: acute cough (last- ing less than 3 weeks), subacute (lasting 3–8 weeks) and chronic (lasting more than 8 weeks). Acute cough is usually caused by self limited viral respiratory infections. However, an attempt should be made to exclude serious causes. Subacute cough is mostly related to acute viral infections (postinfectious cough) and abates without specific treat- ment. If the cough is progressive or if re- tained inhaled foreign body or chronic lung disease is likely, immediate investi- gations are required. Chronic cough is classified into spe- cific and nonspecific. Specific cough is a cough with symp- toms and signs that point to a specific underlying diagnosis; i.e. specific point- ers. Pointers in the child’s history: is cough dry or productive, recurrent, chronic, sudden onset, triggering factors, difficulty feeding, presence of associated symptoms. Pointers in the clinical examination: failure to gain weight, hemopthysis, al- lergy – nose, skin, eye, finger clubbing, pathologic auscultatory signs, dyspnea:.a cough can be a manifestation of conges- tive heart disease with pulmonary ede- ma. Inhaled foreign body Allergic rhinitis First presentation of chronic lung disease History and clinical examination Acute respiratory infection Coryza/ fever Acute onset/ choking Allergic salute Ill health, abnormal chest shape, finger clubbing Bronchoscopy See treatment guidelines (antihistamines, intranasal steroids) Further investigations Predominantly upper respiratory tract Simple cold Laryngitis Bacterial tracheitis Reassure Predominantly lower respiratory tract Bronchiolitis Asthma Pneumonia See treatment guidelines on line editionCough in children Professional artiCle In most children a detailed history and clinical examination will determine the presence of specific pointers, and consequently the need for further inves- tigations (3-5). A nonspecific cough is a dry cough in the otherwise healthy child without associated specific pointers that would point to an underlying disease. In most children with a chronic dry cough there is no serious underlying dis- ease, it is a postinfectious cough due to hypersensitivity of cough receptors after a viral infection. In this group of chil- dren investigations are mostly not nec- essary, although a careful follow up until cough disappears is required (3,4). On the other hand, a chronic wet cough is always the consequence of a serious underlying disease, and further investigations are needed. All children cough from time to time. As childhood coughing is a common problem and has numerous different causes the management of a child with a cough is a big challenge. Recommendations for the assessment of cough in children are very helpful to the pediatrician as they enable a highly structured approach to the diagnosis and treatment, avoidance of unnecessary in- vestigations and help diminish the pos- sibility to overlook serious or even life- threatening conditions  (4,5). However, guidelines cannot be a substitute for a personal approach in clinical decisions. 2. Classification of cough In literature there are different classi- fications regarding the duration of couh- ging. Some authors classify cough as acute if it lasts less than three weeks, and chronic if it lasts more than three weeks. In the recommendations for cough in children by the British Thoracic Society (BTS)(4) and American College of Chest Physicians (ACCP)(5-6) cough is classi- fied as acute, subacute (postinfectious, prolonged acute cough) and chronic. In Slovenia, this classification was used by the Working Group for Pediatric Pul- monology when preparing the national recommendations for the management of cough in children (ref. manjka) Table 1: Questions to be addressed to arrive at a specific diagnosis of acute cough (4). Questions and features Likely diagnoses does a child have acute upper respiratory infection? tracheitis Bacterial sinusitis is stridor accompanying coughing? acute laryngitis Bacterial tracheitis are there any features to suggest a lower respiratory tract illness: tachypnea, increased work of breathing, crackles/wheeze, fever? Pneumonia Bronchiolitis asthma is there anything to suggest hay fever? asthma – likely is there anything to suggest a presentation of a chronic respiratory disorder: failure to thrive, finger clubbing, overinflated chest, atopy? Cystic fibrosis Primary ciliary dyskinesia Bronchiectasis is there anything to suggest an inhaled foreign body: sudden onset or witnessed choking episode? inhaled foreign body on line edition Zdrav Vestn | Maj – June 2017 | Volume 86 CardioVasCUlar systeM 2.1. Acute cough Acute cough lasts less than three weeks and is usually caused by a viral upper respiratory tract infection. The in- tensity of cough is reduced in the second and third week. In the absence of fever, tachypnea, chest symptoms and signs of lower re- spiratory tract infection, cough will most likely abate within 2–3 weeks. The reason that acute cough has been classified as a cough that lasts up to three weeks is that it may take two to three weeks for most infectious causes of cough to fully resolve (4). Acute cough is mostly the due to a viral upper respiratory tract infecti- on, but it can also be a sign of serious life-threatening underlying diseases, such as foreign body aspiration, pul- monary embolism, cardiac decom- pensation, pneumonia or mediasti- nal neoplasm. In a child with acute cough an at- tempt must be made to find whether • the cough is the sign of a serious life-threatening underlying disease OR • whether it is the sign of a mild dis- ease such as the common cold, asth- ma, upper airway syndrome. When a history, clinical examination and investigations point toward a simple viral respiratory infection as the cause of cough, only symptomatic treatment is advised. The children in whom a serious life- threatening condition is a likely cause of acute cough should undergo immediate investigations, and specific treatment must be initiated (Figure 1). When a chest radiograph should be considered in a child with acute cough (4). • possibility of pneumonia: fever and tachipnea in the absence of wheezing, localized auscultatory sign – dullness, crackles or bronchial breathing, if fever and cough last lon- ger than 4–5 days, unusual course of bronchiolitis. • possibility of foreign body aspira- tion: sudden onset of coughing, localized auscultation sign – wheezing, hyper- inflation; X-ray must be performed in inspiration and expiration, but also normal X-ray does not exclude aspiration; bronchoscopy is the most important diagnostic and therapeutic investigation. • possibility of chronic lung disease: failure to thrive, fingers clubbing, hy- perinflation or chest deformity. • unusual clinical course: cough is relentlessly progressive be- yond 2–3 weeks, or recurrent fever af- ter initial resolution: pneumonia, me- diastinal tumor, tuberculosis, foreign body aspiration, atelectasis. • hemoptysis: indicative of pneumonia or lung ab- scess, chronic suppurative lung dis- ease such as cystic fibrosis, inhaled foreign body, tuberculosis, pulmo- nary hemosiderosis, tumor, pulmo- nary arteriovenous malformation. 2.2. Subacute cough Studies and clinical observations show that in the majority of children acute cough with the common cold is associated with bronchitis and cough abates within 2–3 weeks, but 10 % of children will still cough after 4 weeks. Cough gradually improves and a com- plete resolution is expected within 3–8 on line editionCough in children Professional artiCle Figure 2: subacute cough algorithm. weeks (4-6). This data should be known to all health workers and parents to avoid unnecessary visits and investigations. This type of cough is called prolonged acute cough, postinfectious cough or subacute cough. If the child is otherwise well, the cough is dry and specific point- ers for a serious disease are absent, only observation of the child is recommended until complete resolution of the cough. If there is suspicion of a retained in- haled foreign body, or the cough is pro- gressively worsening or there are signs of a chronic disease present, further in- vestigations are needed. Pertussis has been increasingly identified as the cause of prolonged cough even in a previously vaccinated child (10-11). In a child who coughs for more than three but less than eight weeks (su- bacute cough), it is necessary to find whether the cough is associated with an acute respiratory infection or not. A. If subacute cough is due to an acute viral infection in an otherwise healthy child, the cough is dry and gradually improving, specific pointers for a seri- ous disease are absent, the observation of the child is only required until the complete resolution of the cough; no further tests are needed. Most cough- ing in the child is related to transient viral infections, i.e. it is postinfectious (postviral). It starts with other symp- toms of the common cold and per- sists after the other cold signs have abated. There are many mechanisms: viral inflammation is related to hy- persensitivity of the airways, sputum production and impaired airway clearance, which trigger the cough re- ceptors. In most children this cough resolves spontaneously. A period of 3–8 weeks is needed to determine if further tests are needed. If the cough lasts more than 8 weeks, other causes, not only postinfectious cough, should be considered (4-6). B. If subacute cough is not due to an acute respiratory viral infection, the following investigations are required to exclude: • retained inhaled foreign body, Acute onset, sudden choking episode Inhaled foreign body, bronchoscopy Specific pointers identified in history and examination YES, chest X-ray YES NE NO, chest X-ray Progressive cough +/- weight loss No-other than features of: • Post infectious cough • Pertussis like illness Tuberculosis, compressing intrathoracic lesion (mediastinal tumor) Features of chronic lung disease Cough resolved Further period of observation to ensure complete resolution Further investigations on line edition Zdrav Vestn | Maj – June 2017 | Volume 86 CardioVasCUlar systeM • chronic lung disease with acute onset, • pertussis, mediastinal tumor and lung collapse due to mucous plug or pressure due to enlarged lymph node (i.e. tuberculosis) if the cough is progressively worsening (10-11). 2.3. Chronic cough Chronic cough is by majority of guidelines regarded as a cough, which lasts for more than 8 weeks. In com- parison to an acute or subacute cough, a chronic cough is diagnostically more complex, because it could be an effect of several diseases (4,5,12,13). 3. Management of child with chronic cough A structured approach is necessary in the treatment of a child with chronic cough. Most important steps are tak- ing an accurate history and a thorough physical examination. In both steps the focus should be on searching for clinical characteristics, the so-called specific in- dicators that reveal the cause of chronic cough (4,6,12). The results of both patient history and physical examination help with the decision on the investigations need- ed (3,4,6,11). In history taking and in clinical exa- mination the focus should be on spe- cific indicators (information/symp- toms/signs), which lead us to further examinations and help with the dia- gnosis or the cause of cough. 3.1. History The child’s age should be considered when taking the history: the younger the child the higher the probability of ana- tomic disorders in the upper and lower respiratory tract, or digestive tract, and of aspiration of a foreign body. Specific questions must be asked, such as wheth- er a child has feeding problems. Food aspiration can be a cause of chronic cough. In such cases anatomic disorders in the area of digestive and respiratory tracts(tracheoesophageal fistula, laryn- geal cleft,…), and neuromuscular dis- eases must be excluded. The following questions must be asked to obtain a detailed history (4) 1. When and how did the cough start? In cases the cough started suddenly, a foreign body aspiration must be as- sumed. In cases the cough started in the neo- natal period, an important disorder or disease is most probably the cause. All newborns who cough, need a spe- cial attention when feeded, feeding should be done by an experienced person only! Probable causes of cough in the neo- natal period: • aspiration due to tracheoesopha- geal fistula or laryngeal cleft (pro- ductive cough after feeding, irrita- tion, moving the head backwards after feeding), • congenital malformation: com- pression of the airways or tracheo- bronchomalacia, cystic fibrosis, primary ciliary dyskinesia, espe- cially if chronic rhinitis persists from the birth, • infections: in utero (cytomegalo- virus), during labor (Chlamydia trachomatis) or after birth (e.g. re- spiratory syncytial virus). 2. Is cough productive or dry? It is important to distinguish between both variations of cough, which helps us find the cause of cough. With pro- on line editionCough in children Professional artiCle ductive cough phlegm is present in the respiratory tract. 3. Is cough chronic or it occurs with in- tervals of improvement? A detailed history is necessary. 4. Is cough an isolated symptom or are there other symptoms present (wheezing, shortness of breath, asso- ciated ill health)? When cough is isolated in a healthy child, a psychogenic or a recurrent bronchitis could be the cause. When heavy breathing and wheezing are as- sociated with the cough, the cause fo coughing could be asthma, inhaled foreign body retained in the respira- tory tract, recurrent pulmonary aspi- ration, airway compression, tracheo- malacia, bronchiolitis obliterans or interstitial lung disease. 5. What triggers the cough? Exercise, cold air, allergens – possibil- ity of asthma, when a cough occurs in lying position – postnasal drip or Table 2: red flag (4). sudden onset with choking episode neonatal onset Chronic moist cough with phlegm production Cough with feeding, choking, vomiting. associated night sweats/weight loss inspiratory stridor (other than during acute laryngitis) Hemoptysis Continuous unremitting or worsening cough signs of chronic lung disease – (failure to thrive, clubbing, overinflated chest, atopy) abnormalities on respiratory examination and/or chest X-ray Table 3: specific pointers in chronic cough (4,13). Cough characteristics and specific pointers Likely diagnosis dry cough, worse at night; wheezing; atopy asthma, Gor throat clearing, allergic salute allergic rhinitis Upper airway cough syndrome Wet cough Chronic suppurative lung disease (bronchiectasis) e.g, Cf Choking tef, swallow incoordiataion brassy, barking cough, stridor. acute laryngitis, tracheobronchomalacia, pressure on the airways Bizarre cough in a child exhibiting ”la belle indifference” to the cough,which increases with attention, disappears with sleep Psychogenic cough Unremitting cough, losing weight, fever tuberculosis staccato cough Chlamydia trachomatis infection Paroxysmal cough with or without an inspiratory ”whoop” and vomit Bordetella pertussis infection dry cough, crackles, restrictive spirometry ild GOR-gastroesophageal reflux; CF-cystic fibrosis; TEF-tracheoesophageal fistula; ILD-interstitial lung disease on line edition Zdrav Vestn | Maj – June 2017 | Volume 86 CardioVasCUlar systeM gastro-esophageal reflux, postpran- dial cough – food aspiration. 6. Does anyone else in the family suffer from respiratory disease? 7. What medication is the child on and how do they affect the cough? 8. Does the cough disappear when asleep? 9. Does the child (teenager) smoke ciga- rettes or is she/he exposed to environ- mental smoke? 3.2. Clinical examination Pointers in the clinical examination 1. Full clinical systematic examina- tion must be done to estimate the nutritional status and the area of the ears, nose and throat (foreign body in external auditory meatus may be the cause of chronic cough). 2. Look for the signs of atopic disease: atopic dermatitis, allergic rhinocon- junctivitis. 3. Look for the signs of chronic lung disorder: failure to thrive, presence of otitis and/or sinusitis, overinflated chest, finger clubbing, wheezing and/ or crackling lung sound. 4. Look for the signs of chronic car- diac disease: especially in infancy a chronic cough can be a sign of con- gestive heart failure with pulmonary edema. Table 4: serious diseases with chronic productive cough as a leading symptom (4). Condition Investigations Cystic fibrosis sweat test, assessment of pancreatic function, genotyping immune deficiencies differential white cell counts, immunoglobulin levels and subsets, functional antibody responses and lymphocyte subset analysis Primary ciliary disorders screening with feno, ciliary ultrastructure and function, culture of ciliated epithelium, genetic testing Protracted bacterial bronchitis Chest radiography, sputum for culture, exclusion of other causes in this table. response to 4–6 weeks antibiotic and physiotherapy, Ct scan recurrent pulmonary aspiration: laryngeal cleft, tef, neuromuscular or neurodevelopmental disorder, Gor, hiatal hernia Barium swallow, 24 h pH studies, videolaryngoscopy lipid-laden macrophage index on bronchalveolar lavage if bronchoscopy indicated. there is little evidence that Gor alone is the cause of cough in otherwise healthy children retained inhaled foreign body Chest radiography and Ct scan may show focal lung disease rigid bronchoscopy is both diagnostic and therapeutic; indicated almost always if the history is suggestive of inhaled retained foreign body tuberculosis Chest radiography, Mantoux test, early morning gastric aspirates and gamma interferon tests anatomical disorder (e.g.bronchomalacia) or lung malformation (e.g. cystic congenital thoracic malformation) Bronchoscopy and Ct scan interstitial lung disease spirometry (restrictive defect), chest radiography and Ct scan, open lung biopsy FeNO-fraction of exhaled nitric oxide; CT-computer tomography; TEF-tracheoesophageal fistula, GOR-gastroesophageal reflux. on line editionCough in children Professional artiCle 3.3. Investigations On the first examination it is recom- mended to perform the following exam- inations: 1. Chest radiograph 2. Spirometry (only if the child is old enough to perform the maneuvres): provides information on lung vol- umes and airway caliber. 3. Sample of sputum for microbiologi- cal assessment in productive cough. 4. Allergy testing: positive allergen tests increase the likelihood of asthma to be the cause of coughing. 5. Otorhinolaryngologic examination in the presence of specific indica- tors: throat clearing type of cough, allergic salute (Table 3). IMPORTANT: When examining a child with a cough we must not igno- re the warning signs indicating the cough to result from a serious under- lying disease or condition – red flag. Chronic cough can be divided into a specific and non-specific cough, based on the presence or absence of specific point- ers in the history and on clinical exami- nation. An Australian study supports this division because the presence of clinical pointers suggests which children with chronic cough are at a higher risk of an important underlying disease and need immediate targeted intervention, where- as the children without specific pointers are at a low risk of an underlying disease not needing detailed investigations on first examination. Regular follow-up is sufficient. The authors have concluded that chronic productive cough is the most accurate indicator reliably predict- ing the presence of an underlying seri- ous chronic lung disease (14). A recent study showed that the most common symptom in more than 80 % of children with primary ciliary dys- kinesia who visited a doctor for the first time was chronic or recurrent cough (15). In order to avoid antibiotic overuse we recommend performing diagno- stic management and treatment of children with suspected protracted bacterial bronchitis in a tertiary level unit for pulmonary diseases. In an otherwise healthy child with chronic dry cough only the basic inves- tigations are performe at the primary care level (Table 4). However, the child should be regularly followed-up in order not to overlook the development of a po- tentially serious disease (4,6). The most common causes of chronic dry cough (recurrent upper respiratory tract infections and bronchitis, postviral cough, upper airway cough syndrome, allergic rhinitis and psychogenic cough) are listed in Table 5 and apply only to healthy children WITHOUT any sign of a chronic lung disease. Often, the child’s age help us clar- ify the cause of cough. Some causes of cough are more common in a certain age group. The most common causes of cough by age are listed in Table 6. 3.4. Treatment of cough • None of the studies has yet proved that symptomatic treatment with an- titussives and mucolytics is effective despite large amounts of money be- ing spent on various over-the-counter medications  (4,6,22). Some medica- tions have important side effects (23). Unnecessary and ineffective symp- on line edition Zdrav Vestn | Maj – June 2017 | Volume 86 CardioVasCUlar systeM Table 5: Causes, patterns and potential investigations of chronic cough in otherwise healthy children (4). Cause Pattern Potential investigations frequently recurring viral bronchitis Crowded living conditions, and attendance in child care nursery in winter months. Parents report that the child coughs ”all the time”. on detailed history they recall that periods of resolution are between episodes of cough. those children are basically healthy. rhinovirus, rsV, adV, B. pertussis, M. pneumoniae and C. pneumoniae. The incidence of upper respiratory infections (with cough) in children < 4 years is 5 to 8 episodes, in children 10–14 years 2 to 5 episodes per year. • none • Consider chest radiography • examine during the symptom- free period Postinfectious cough troublesome cough (day and night) following respiratory infection, it lasts mostly to three weeks, in 5 % of children it resolves slowly over next 2–3 months. Viral respiratory infections, C. pneumoniae and M. pneumoniae. • none, chest radiography. • on rare occasions consider trial of asthma therapy as some mild asthmatics have prolonged recovery from each viral infection Pertussis troublesome spasmodic cough after infection with B. pertussis which slowly resolves over 3–6 months, but it can last up to 1 year. Vomiting of clear tenacious mucus. • none. • Consider chest radiography. • Positive serology or culture may be helpful in reducing requirements for further investigations. • if pertussis has been diagnosed, macrolide antibiotics given in the first 2 weeks in the course of the disease can slightly alter the clinical course but their main role is to reduce the period of infectivity. allergic rhinitis, upper airway cough syndrome – UaCs (formerly called postnasal drip syndrome) Postnasal drip syndrome is now called UaCs because it is unclear whether the mechanism of cough is postnasal drip, direct irritation, or inflammation of the cough receptors in the upper airway. not fully accepted as the cause of cough. Children with allergic rhinitis may have dennie-Morgan lines and transverse nasal crease of ”allergic salute” from frequent nose rubbing. • ent examination, • chest radiography, • allergy tests Psychogenic cough (”somatic cough syndrome”) Usually in an older child/adolescent. dry, tic-like cough persisting after head cold or during times of stress. Child does not look ill. Cough goes away with concentration and sleep. Child is exhibiting ”la belle indifference”. • it is important to do investigations to assure the doctor and parent that no major disease is being overlooked. it is important not to keep performing futile investigations that may reinforce the underlying problem. on line editionCough in children Professional artiCle Figure 3: algorithm for the management of child with chronic cough tomatic cough treatment can extend the time to diagnosis and increase the possibility of complications. • The treatment of cough should be targeted according to the cause. The management of cough relates to mak- ing an accurate underlying diagno- sis first, and then applying a specific treatment for that condition accord- ing to the guidelines. • The most common diseases that pres- ent primary with coughing and have specific guidelines for the treatment are asthma, cystic fibrosis, immune deficiencies, primary ciliary dyski- nesia and tuberculosis. We use anti- biotics to treat early infection with B. Pertussis and in a hospital protracted bacterial bronchitis, but only after ex- clusion of other causes and underly- ing diseases. • In an otherwise healthy child with dry cough and without specific pointers the treatment is often empirical with anti-asthma medications (inhaled corticosteroids), medications for al- lergic rhinitis and gastroesophageal reflux. However, the results show that these medications are generally not effective (4,6). In younger children it is usually impossible to exclude the diagnosis of asthma with certainty, therefore it is recommended to con- sider a trial of anti-asthma therapy with inhaled corticosteroids in some of them. The duration of therapy needs to be accurately defined (8–12 weeks) together with predefined Asthma Specific pointers identified from history, examination chest X-ray, spirometry (> 5 years) Wheezing episodes, atopy Clearing throat, allergic salute Productive cough Choking with feeds BDR: bronchodilator responsiveness test; PEFR: peak expiratory flow rate Brassy or barking cough Dry and bizarre cough, “la belle indifference”, disappears when asleep Dry cough, breathlessness, crackles, restrictive spirometry Progressive cough, weight loss, fevers NO YES NO No response Response YES BDR test/ PEFR monitoring at home Post nasal drip/ allergic rhinitis Recurrent aspiration Tracheo/bronchomalacia, airways compression Tuberculosis Psychogenic cough Interstitial lung disease Chronic purulent lung disease:: • Cystic fibrosis • Primary ciliary dyskinesia • Protracted bacterial bronchitis • Immune deficiency Isolated dry cough in otherwise healthy child Is the cough troublesome? Stop inhaled glucocorticoids Reassure, follow-up Consider further investigations and follow-up Restart treatment if cough relapses Therapeutic trial with inhaled glucocorticoids 8-12 weeks on line edition Zdrav Vestn | Maj – June 2017 | Volume 86 CardioVasCUlar systeM goals of therapy. Strict criteria need to be met in order to prevent unneces- sary and long-term treatment of chil- dren with recurrent viral bronchitis or subacute (postviral) cough with inhaled corticosteroids (4,24). 4. Conclusion Cough is one of the most common symptoms for which patients seek medi- cal attention. It is usually caused by viral respiratory tract infections and resolves spontaneously. However, sometimes it is caused by a serious and life-threatening disease. This is why the treatment of cough in children can be challenging. The recommendations for the man- agement of children with cough include a structured approach that can prevent overlooking an underlying potentially serious disease and at the same time help to avoid unnecessary investigations and ineffective cough treatment. Acute cough is mostly due to an acute viral respiratory tract infection. Never- theless, it can also be caused by a serious and life-threatening disease. At the first visit we need to evaluate the possible causes and decide if there is any need for immediate further investigations or fol- low-up. The absence of fever, tachypnea and normal auscultatory lung examina- tion exclude the possibility of complica- tions with high probability. Many studies and clinical observa- tions show that in most children a cough related to acute viral respiratory tract infection resolves after 2–3 weeks, but in 10 % of children it can last for more than 4 weeks (subacute cough). The most common cause of subacute cough is respiratory tract infection (mostly with B. Pertussis) that needs follow-up only. If there is a risk of an overlooked foreign body aspiration, if there are any signs suggesting a chronic lung disease or if the cough intensifies, immediate diagnostic evaluation and treatment are needed. Unlike acute and subacute cough, chronic cough is the most difficult to diagnose, because it can be caused by many diseases. Considering the pres- ence of certain clinical characteristics or pointers in the history and on clinical ex- amination that suggest a possible cause, we distinguish specific and non-specific cough. The presence of specific pointers (e..g. productive cough) suggests an un- derlying disease and requires immediate diagnostic management and treatment. On the contrary, the absence of spe- cific pointers in an otherwise healthy Table 6: the most common causes of cough by age (3,21). < 1 year 1–6 years > 6 years • Gor • anatomical disorders (double aortic arch, bronchogenic cysts) or lung malformation (e.g. cystic congenital thoracic malformations, tef) • Congenital heart disease • neonatal infections • Cystic fibrosis • Passive smoking • environmental pollution • respiratory infections– postinfectious cough • asthma • Gor • inhaled foreign body • anatomical disorders (tracheobronchomalacia, bronchogenic cysts, lung sequester) • immune deficiency Bronchiectasis • Passive smoking • asthma • Upper airway cough syndrome • Psychogenic cough • Gor • Bronchiectasis • anatomical disorders (bronchogenic cysts, lung sequester) • tumors TEF- tracheoesophageal fistula, GOR- gastroesophageal reflux. on line editionCough in children Professional artiCle child with chronic dry cough excludes a potentially serious disease with high probability. 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