Some Causes of Cough in Children
Cause | Suggestive Findings | Diagnostic Approach |
|---|---|---|
Acute | ||
Bacterial tracheitis (rare) | URI-like prodrome, stridor, barky cough, high fever, respiratory distress, toxic appearance, purulent secretions | Anteroposterior and lateral neck x-rays Possibly bronchoscopy |
Rhinorrhea, tachypnea, wheezing, crackles, retractions, nasal flaring, possible posttussive emesis In infants up to 24 months; most common among those 3–6 months | Clinical evaluation Sometimes chest x-ray Sometimes nasal swab for rapid viral antigen or PCR assays or viral culture | |
Fever, nasal congestion and rhinorrhea, sore throat, chest tightness, tachypnea, wheezing, crackles, hypoxia | Clinical evaluation Rapid viral antigen or PCR testing Sometimes chest x-ray | |
URI-like prodrome, barky cough (worsening at night), stridor, nasal flaring, retractions, tachypnea | Clinical evaluation Sometimes anteroposterior and lateral neck x-rays | |
Exposure to tobacco smoke, perfume, or ambient pollutants | Clinical evaluation | |
Epiglottitis (rare) | 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 |
Foreign body | Sudden onset of cough and/or choking No fever initially No URI prodrome | Chest x-ray (inspiratory and expiratory views) Sometimes bronchoscopy |
Pneumonia (viral, bacterial) | 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 | Chest x-ray |
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 | Clinical evaluation Sometimes CT | |
Rhinorrhea, red swollen nasal mucosa, possible fever and sore throat, shotty cervical adenopathy (many small nontender nodes) | Clinical evaluation | |
Chronic* | ||
Airway lesions (tracheomalacia, tracheoesophageal fistula) | Tracheomalacia: Congenital stridor or barky cough, possible respiratory distress Tracheoesophageal fistula: History of polyhydramnios (if accompanied by esophageal atresia), cough or respiratory distress with feeding, recurrent pneumonia | Tracheomalacia: Airway fluoroscopy and/or bronchoscopy Tracheoesophageal fistula: Attempt passage of a catheter into the stomach (helps in diagnosis of tracheoesophageal fistula with esophageal atresia) Chest x-ray Contrast swallowing study, including esophagography Bronchoscopy and endoscopy |
Intermittent episodes of cough with exercise, allergens, weather changes, or URIs Nighttime cough Family history of asthma History of eczema or allergic rhinitis | Clinical evaluation Trial of asthma drugs Pulmonary function tests | |
Atypical pneumonia (mycoplasma, Chlamydia) | Gradual onset of illness Headache, malaise, muscle soreness Possible ear pain, rhinitis, and sore throat Possible wheezing and crackles Persistent staccato cough | Chest x-ray Polymerase chain reaction testing |
Birth defects of the lungs (eg, congenital adenomatoid malformation) | Several episodes of pneumonia in the same part of the lungs | Chest x-ray Sometimes CT or MRI |
History of meconium ileus, recurrent pneumonia or wheezing, failure to thrive, foul-smelling stools, clubbing or cyanosis of nail beds | Sweat chloride test Molecular diagnosis with direct mutation analysis | |
Foreign body | History of acute onset of cough and choking followed by a period of persistent cough Possible development of fever No URI prodrome Presence of small objects or toys near child | Chest x-ray (inspiratory and expiratory views) Bronchoscopy |
Gastroesophageal reflux | 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) | Infants: Clinical evaluation Sometimes upper gastrointestinal study for determination of anatomy Trial of H2 blockers or a proton pump inhibitor Possible esophageal pH or impedance probe study Older children: Clinical evaluation Trial of H2 blockers or proton pump inhibitors Possible endoscopy |
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 | |
Allergic rhinitis with postnasal drip | 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 |
Postrespiratory tract infection | History of respiratory infection followed by a persistent, staccato cough | Clinical evaluation |
Primary ciliary dyskinesia | History of repeated upper (otitis media, sinusitis) and lower (pneumonia) respiratory tract infections | Chest x-ray Sinus x-ray or CT Chest CT Microscopic examination of living tissue (typically from sinus or airway mucosa) for cilia abnormalities |
Psychogenic cough | Persistent barky cough, possibly prominent during classes and absent during play and at night No fevers or other symptoms | Clinical evaluation |
History or risk of exposure Immunocompromise Sometimes fever, chills, night sweats, lymphadenopathy, weight loss | Tuberculin skin test (PPD) Sputum culture (or morning gastric aspirate culture for children < 5 years) Chest x-ray | |
* All patients require a chest x-ray when they present for the first time with chronic cough. | ||
PCR = polymerase chain reaction; URI = upper respiratory infection. | ||