Excerpt for Chronic Cough In Children, A Simple Guide To The Condition, Diagnosis, Treatment And Related Conditions by , available in its entirety at Smashwords

Chronic Cough

In Children,





The Condition,




Related Conditions


Dr Kenneth Kee

M.B.,B.S. (Singapore)

Ph.D (Healthcare Administration)

Copyright Kenneth Kee 2017 Smashwords Edition

Published by Kenneth Kee at Smashwords.com


This book is dedicated

To my wife Dorothy

And my children

Carolyn, Grace

And Kelvin

This book describes Chronic Cough In Children, Diagnosis and Treatment and Related Diseases which is seen in some of my patients in my Family Clinic.

(What The patient Need to Treat Chronic Cough In Children)

This eBook is licensed for your personal enjoyment only. This eBook may not be re-sold or given away to other people. If the patient would like to share this book with another person, please purchase an additional copy for each reader.

If you’re reading this book and did not purchase it, or it was not purchased for your use only, then please return to Smashwords.com and purchase your own copy.

Thank you for respecting the hard work of this author.


I have been writing medical articles for my blog http://kennethkee.blogspot.com (A Simple Guide to Medical Disorder) for the benefit of my patients since 2007.

My purpose in writing these simple guides was for the health education of my patients.

Health Education was also my dissertation for my Ph.D (Healthcare Administration).

I then wrote an autobiolographical account of his journey as a medical student to family doctor on his other blog http://afamilydoctorstale.blogspot.com.

This autobiolographical account “A Family Doctor’s Tale” was combined with my early “A Simple Guide to Medical Disorders” into a new Wordpress Blog “A Family Doctor’s Tale” on http://kenkee481.wordpress.com.

From which many free articles from the blog was taken and put together into 800 amazon kindle books and 200 into Smashwords.com eBooks.

Some people have complained that the simple guides are too simple.

For their information they are made simple in order to educate the patients.

The later books go into more details of medical disorders.

The first chapter is always from my earlier blogs which unfortunately tends to have typos and spelling mistakes.

Since 2013, I have tried to improve my spelling and writing.

As I tried to bring the patient the latest information about a disorder or illness by reading the latest journals both online and offline, I find that I am learning more and improving on my own medical knowledge in diagnosis and treatment for my patients.

Just by writing all these simple guides I find that I have learned a lot from your reviews (good or bad), criticism and advice.

I am sorry for the repetitions in these simple guides as the second chapters onwards have new information as compared to my first chapter taken from my blog.

I also find repetition definitely help me and maybe some readers to remember the facts in the books more easily.

I apologize if these repetitions are irritating to some readers.

Chapter 1

Chronic Cough in Children

Chronic Cough in Children is very commonly seen at the family doctor clinic.

Up to 7-10 % of preschool and primary school children may have chronic cough without wheeze at some time.

That is the reason why I am writing about this subject.

What is Chronic Cough in Children?

Cough in children may occur from causes anywhere along the airway, from the nose to the alveoli.

Cough is a non-specific reaction to irritation anywhere from the pharynx to the lungs.

Childhood coughing is a frequent disorder that can cause anxiety in parents.

There are significant differences from adult cough in terms of possible causes and treatment guidelines.

Chronic cough in children is described as a cough that last longer than eight weeks.

This time period is used because most acute infective causes of cough will recover in 3-4 weeks, and the eight-week definition identifies those who may require more investigations.

Occasionally post infective cough may persist longer (3-8 weeks) as in the case of pertussis or post viral cough.

Young children may get repeat occurrences of viral respiratory tract infection up to 6-8 times per year and this may be mistaken for chronic cough.

These guidelines notice that the time period between acute and chronic cough (3-8 weeks) is sometimes called 'sub-acute cough' or 'prolonged acute cough' (e.g., a slowly resolving post-viral cough).

If a cough is beginning to recover after three weeks, more time may be permitted before investigating further.

If the cough does not improve by the third week or is getting worse in severity, earlier investigations may be required.

In most guidelines, chronic cough is described as a cough lasting more than 8 weeks

These guidelines are based on the natural history of the most frequent cause of acute cough, upper respiratory tract infections.

Studies indicate that in 90% of children with acute upper respiratory tract infections, the cough has settled within 25 days or 3 and half weeks.

Types of Chronic cough:

Chronic cough may be classified as:

1. Specific cough (in which there is no identifiable cause)

2. Non-specific cough (persistent isolated dry cough in otherwise well children with no signs of respiratory disease and normal investigations)


Surveys show that parent-reported cough (as an isolated symptom) is frequent

The incidence of chronic cough in children has been documented as being as high as 5-10%.

What are the causes of Chronic Cough in Children?


There is a wide range of possible reasons.

Acute Cough in Children (Lasting Two Weeks or Less)

The majority of children have brief repeated periods of coughing because of viral upper respiratory tract infections, such as the common cold.

Healthy preschool children in day care can have up to 8 viral respiratory infections with a cough every year, each lasting about 10 days.

Rarely, a cough happens because of a foreign body in the airway.

This may happen after an episode of choking, but occasionally the choking episode might not be observed, particularly in younger children.

Chronic Cough in Children

There are many different reasons for a persistent or chronic cough in children.

The three most frequent causes of chronic cough in adults (asthma, postnasal drip syndrome and gastro-esophageal reflux) are not always the most frequent in children

Isolated cough is now thought to be abnormal as a manifestation of asthma in children, which normally is linked with other presenting symptoms.


Most children with asthma have inflamed or swollen airways, which often cause repeat occurrences of episodes of cough, wheezing and shortness of breath.

But occasionally the only symptom is a cough that is made worse by viral infections, or this cough happens while the child is asleep, or may be activated by exercise and cold air.

Investigations are spirometry and allergy testing.

Nasal and Sinus Disease

Postnasal drip produced by rhinitis or a sinus infection (sinusitis) can induce chronic cough.

Normally other symptoms such as nasal blockage and congestion or sneezing are present, but occasionally the only symptom observed is the cough.

Investigation is allergy testing for nasal allergens.

Stomach and Esophageal Disorders

In some children, the reason of chronic cough is stomach fluid moving back up the throat.

This is called "reflux" and may happen silently without heartburn.

Some children may form a hoarse voice and choking as symptoms from acid irritating the vocal cords or throat.

To find out this cause, the doctor may do tests to see if acid is refluxing up out of the stomach.

Other investigations are gastroscopy or Esophago-gastro-duodenoscopy.

Post-Viral Infections

Following a viral respiratory infection, healthy children can have a cough lasting for weeks.

There is no specific treatment for this cough, which ultimately goes away.

Cough suppressant medicines can be given in school-age children, but they do not always solve the disorder.

There is always a history of recent infection and paroxysmal cough

Investigations are Chest X-ray and blood tests.

Bacterial Infection of the Lower Airway

Bacteria occasionally can infect the lower airways and produce irritation and cough.

It is not known why this happens, and occasionally the best course of action is not known.

The doctor will help the parent sort out whether this may be relevant in the child.

There is often a history of recent infection and paroxysmal cough

Investigations are Chest X-ray and TB testing (culture, sputum test and skin test)

Inhaled Foreign Body

Foreign bodies, such as toys and food, can be incidentally inhaled at any age, but most often happens at ages two to four years.

It can produce a cough to persist for many weeks to months until the foreign body is found.

There is a history indicative of foreign body inhalation.

Investigations are CXR and bronchoscopy

"Habit" Cough

This is a chronic cough that has no obvious physical cause.

It sometimes lasts after a simple viral respiratory infection.

The cough is normally dry and repetitive or is a "honking" cough.

Habit cough normally happens only when the child is awake, not sleeping.

A neuromuscular tic can also produce this kind of cough.

Irritant Cough

Exposure to tobacco smoke and other air pollutants (smoke and exhaust from wood burning, air pollution and exhaust from vehicles) can result in cough and may worsen the cough linked to asthma or rhinitis.

There is a history indicative of second hand smoke or pollutant inhalation.

Investigations are CXR and spirometry

Frequent causes in primary care

1. Infections (or recurrent infections) - including respiratory syncytial virus (RSV), adenovirus, Mycoplasma pneumoniae, chlamydial pneumonia, whooping cough (pertussis) and tuberculosis.

2. Asthma.

3. Postnasal drip syndrome.

4. Environmental agents - tobacco smoke, possibly charcoal or kerosene heaters.

5. Gastro-esophageal reflux.

Less frequent causes are:

1. Inhaled foreign body.

2. Cystic fibrosis.

3. Immune deficiency.

4. Congenital lesions - e.g., tracheo-esophageal fistula, tracheomalacia.

5. Ciliary dyskinesia.

6. Neurological - e.g., tics, psychogenic cough.

Psychogenic cough may be bizarre, honking and reduce with sleep or attention to other activities.

What are the symptoms of Chronic Cough in Children?

Doctors should assess chronic cough in children, looking for a specific cause, and for any 'red flags'


1. Nature of cough:

a. The sound - e.g., brassy or seal-like (indicates tracheal or glottic irritation); bizarre or honking (indicates psychogenic); croupy, staccato and paroxysmal or barking (indicates croup).

b. Wet or dry (productive or not) - young children do not cough sputum but may vomit it.

c. Hemoptysis or sputum.

2. Onset, duration, time course of cough.

a. Triggers.

When sleeping the cough may disappear

3. Other symptoms – such as fever, weight loss, night sweats.

4. Family history - particularly atopy or respiratory disease.

5. Medicine. Cough is a frequent side-effect of angiotensin-converting enzyme (ACE) inhibitors.

6. Cigarette smoke exposure or other environment pollutants - e.g., heating fuel.

Physical Examination

Physical examination should be complete and should include assessment of growth (weight, height and BMI), ENT and respiratory examination.

A normal physical examination does not exclude significant pathology.

1. General signs - fever, height/weight and any failure to thrive, clubbing, lymphadenopathy, signs of atopy.

2. Upper airway - abnormal voice or crying, inspiratory stridor, ENT examination.

3. Respiratory signs - dyspnea, respiratory rate, chest auscultation.

4. Observation of the cough if possible.

5. Pointers to special causes of chronic cough


1. Neonatal onset of cough - suggest congenital malformations, aspiration, lung infections, cystic fibrosis.

2. Very acute onset – suggest inhaled foreign body.

Systemic illness

1. Child well, no other symptoms - indicate non-specific isolated cough, recurrent viral bronchitis, psychogenic cough, habit cough (dry repetitive cough which disappears with sleep).

2. Systemic ill health or recurrent pneumonia - consider tuberculosis, inhaled foreign body, cystic fibrosis, immune disorders, persistent bronchitis, recurrent aspiration.

Nature of cough

1. Related to wheezing or breathlessness - indicate asthma, inhaled foreign body, recurrent pulmonary aspiration, cardiac disease, airways compression, tracheobronchomalacia, bronchiolitis.

2. Related shortness of breath and restrictive lung defect – indicates interstitial lung disease.

3. Cough happens in paroxysmal spasms with an inspiratory 'whoop' – indicates whooping cough.

4. Cough is brassy, croupy or bizarre and honking - indicate tracheal or glottic irritation and psychogenic causes.

5. 'Wet' or productive cough (most young children do not expel sputum but tend to swallow it) - indicate bronchiectasis or any suppurative lung disorder - e.g., cystic fibrosis.

6. Relentlessly progressive cough - indicate inhaled foreign body, lobar collapse, tuberculosis, rapidly expanding intrathoracic lesion.

7. True hemoptysis (apparent hemoptysis may be related to nosebleeds, cheek biting or hematemesis) - indicate pneumonia, lung abscess, bronchiectasis, retained inhaled foreign body, tuberculosis, pulmonary hypertension.


1. Exercise/excitement/cold air/nocturnal cough/change in environment (e.g., pets) - indicate asthma.

2. Swallowing/meals – indicate recurrent aspiration.

3. Lying down - indicate postnasal drip, gastro-esophageal reflux.

4. Attention - indicate psychogenic.

Mannerisms related with abnormal stereotypical coughs - indicate Tourette's syndrome (even though the diagnosis of Tourette's syndrome cannot be made on a single tic, including isolated cough).

How is chronic cough of children diagnosed?


These medical features indicate a possible serious cause of cough:


1. Family history of lung disease.

2. Neonatal onset of cough.

3. Sudden onset of cough.

4. Hemoptysis (true hemoptysis - not, for example, nosebleeds or cheek biting).

5. Cough with feeding, dysphagia (swallowing difficulty), severe vomiting.

6. Chronic wet cough with sputum production.

7. Cough started and persisted after a choking episode

8. Cough that occurs during or immediately after feeding

9. Continuous unremitting or worsening cough.

10. History of contact with TB

11. Suggestion of immune deficiency

12. Recurrent pneumonias or other significant lung diseases

13. Night sweats/weight loss.


1. Signs of chronic lung disease - e.g., clubbing.

2. Failure to thrive.

3. Abnormal voice or crying, inspiratory stridor.

4. Focal chest abnormality.

5. Abnormal respiratory examination

6. Neuromuscular disease

7. Cardiac abnormalities


Primary care guidelines suggest this strategy:

1. 'Red flags' present - require specific investigations depending on the clinical picture.

2. No 'red flags':

a. If fever - exclude pneumonia.

b. For immigrants - exclude tuberculosis.

If there are pointers to a specific cause - investigate properly (e.g., spirometry, serology, esophageal pH monitoring).

If there are no specific pointers - suggest CXR.

Guidelines indicate the method when investigating the causes of chronic cough:

Initial investigations:

1. CXR.

2. Spirometry where possible in older children ± tests of bronchodilator responsiveness or bronchial hyper-reactivity.

Further investigations:

1. Sputum sample if possible - for microbiology and cytology.

2. Allergy testing (skin prick or radioallergosorbent test (RAST) specific testing) may help if atopy/asthma is likely diagnoses.

Other tests will depend on the medical picture and differential diagnosis.

1. Trial of treatment:

Guidelines indicate that in contrast with adults, for children with a dry cough who are well and have no specific disease pointers, empirical trials of treatment (for asthma, allergic rhinitis or gastro-esophageal reflux) tend not likely to be beneficial and are normally not advised.

In young children, guidelines indicate that, as it may be difficult to exclude asthma as a cause of coughing in young children, a trial of anti-asthma therapy may be done (e.g., inhaled corticosteroids).

Effective delivery, adequate doses and clear recording of outcomes must be ensured.

A time (e.g., 8-12 weeks) must be set after which the trial of anti-asthma medicine should be stopped.

If the child has reacted well to anti-asthma therapy and the treatment has later been stopped, an early relapse that again reacts to treatment is indicative of cough-variant asthma.

If there is no reaction, asthma is not likely.

What is the Treatment of Chronic cough in children?


This is dependent on any specific cause found.

1. In a well child with no 'red flags', the doctor should aim to prevent invasive investigations and to reduce the expectations and anxieties of parents.

2. Persistent cough produces a significant load in terms of repeated treatments and parental anxiety.

3. Environmental contributions should be removed if possible - e.g., tobacco smoke.

No treatment has been discovered to be especially effective for isolated nonspecific cough in an otherwise well child.

Reassurance is essential, and it will normally subside over time.

Anti-tussive drugs, other than simple cough linctus, are not normally advised.

If the child has a daytime cough after a viral respiratory infection, it normally does not need any specific treatment especially if it goes away in one or two weeks.

The main treatment for chronic cough should be based on the underlying cause.

This search for the cause normally requires visiting the doctor.

Also consult the doctor if the child's cough:

1. Is increasingly frustrating,

2. Persists longer than the parent thinks is reasonable,

3. If blood is coughed up or

4. If the cough disrupts the child's daily activities.

Over-the-counter mucous thinning agents such as guaifenesin, and cough suppressing medicines such as dextromethorphan can be given.

While most of the over-the-counter cough medicines are not believed to be particularly effective, it is possible that one might work better in the child than in other children.

If the parent thinks the child may have asthma, make an appointment with an allergist or immunologist.

An allergist is the best doctor to diagnose and treat the asthma.

Healthy Prevention Tips

1. A cough protects the child's body by eliminating mucus, irritating substances and infections from his or her respiratory tract

2. If the child has a cough that persists more than two to three weeks, the parent should schedule a visit with the doctor.

3. Coughing that persists more than 8 weeks is indicated chronic.

It may be produced by asthma, allergic rhinitis (hay fever), reflux or other causes.

An allergist is often the best specialist to find out the cause.

Coughing is an essential way to keep the throat and airways clear.

But too much coughing may mean the child has a disease or disorder.

Some coughs are dry.

Others are productive.

A productive cough is one that carries up mucus.

Mucus is also called phlegm or sputum.

Coughs can be either acute or chronic:

Acute coughs normally begin rapidly and are often because of a cold, flu, or sinus infection.

They normally go away after 3 weeks.

Sub-acute coughs can persist for 3 to 8 weeks.

Chronic coughs persist longer than 8 weeks.

Home Care

If the patient has asthma or another chronic lung disease, the parent should make sure the patient is taking medicines prescribed by the doctor.

Here are some ways to help reduce the cough:

If the patient has a dry, tickling cough, cough drops or hard candy can be given.

The parent should never give these to a child under age 3, because they can cause choking.

The child should use a vaporizer or take a steamy shower.

These raise moisture in the air and help soothe a dry throat.

Plenty of fluids should be consumed.

Liquids assist the mucus to become thinner in the throat making it easier to cough it up.

The parent should not smoke and the child should stay away from secondhand smoke

Medicines the patient can buy are:

1. Guaifenesin helps to break up mucus.

2. The parent should follow package instructions on how much to take.

3. The child should not take more than the recommended amount.

4. The patient should drink lots of fluids if the patient takes this medicine.

5. Decongestants help to clear a runny nose and alleviate postnasal drip.

The parent should consult the child's doctor before the parent gives children ages 6 years or younger an over-the-counter cough medicine, even if it is labeled for children.

These medicines tend not to work for children, and may have serious side effects.

If the patient has seasonal allergies, such as hay fever, the child should:

1. Stay indoors during days or times of the day (normally the morning) when airborne allergens are high.

2. Keep windows closed and use an air conditioner.

3. The child should not use fans that draw in air from outdoors.

4. Shower and change the clothes after being outside.

If the patient has allergies year-round, the child should:

1. Cover the pillows and mattress with dust mite covers,

2. Use an air purifier, and

3. Avoid pets with fur and

4. Other triggers.

For asthmatic patients, a child with asthmatic attack may be treated with bronchodilator inhalers or a nebulizer.

Steam inhalations help dissolve the mucus and help the child breathe better.

Physiotherapy, swimming and breathing exercises help to improve the airways and hence breathing.

Chapter 2

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