Cough in Children: Clinical Evaluation & Diagnosis Learning Tool

Clinical History Assessment

Systematic approach to history taking for a child presenting with cough

Physical Examination Guide

Systematic approach to examining a child with cough

Diagnostic Approach

Initial Assessment

For a child presenting with cough, the initial assessment should include:

• Detailed history focusing on cough characteristics, duration, and associated symptoms
• Complete physical examination focusing on respiratory, ENT, and cardiovascular systems
• Assessment of severity and impact on daily activities including sleep
• Evaluation of risk factors and exposures (allergens, irritants, infections)

Classification of Cough in Children

Different classifications help guide evaluation and management:

Classification	Definition	Key Features
Acute Cough	Duration < 2 weeks	Most commonly viral, self-limiting
Subacute Cough	Duration 2-4 weeks	Post-infectious, resolving inflammation
Chronic Cough	Duration > 4 weeks	Requires thorough investigation, suggests underlying disorder
Specific Cough	Diagnostic clues suggest specific disease	Accompanying symptoms point to etiology
Non-specific Cough	Dry cough without diagnostic features	May need watchful waiting before extensive workup

Differential Diagnosis by Age Group

Age Group	Common Causes	Red Flags
Neonatal (<1 month)	- Congenital anomalies - Tracheoesophageal fistula - Aspiration - Choanal atresia - Laryngomalacia	- Cough with feeding - Cyanosis - Respiratory distress - Stridor - Failure to thrive
Infants (1-12 months)	- Viral bronchiolitis - Pertussis - Viral infections - Aspiration - Early asthma	- Paroxysmal cough with whoop - Post-tussive vomiting - Apnea - Poor feeding - Persistent wheeze
Toddlers/Preschool (1-5 years)	- Viral URI/bronchitis - Asthma/reactive airway disease - Post-nasal drip - Foreign body aspiration - Croup	- Sudden onset cough/choking - Unilateral wheeze - Stridor - Recurrent pneumonia - Persistent nocturnal cough
School-Age (6-12 years)	- Asthma - Sinusitis - Allergic rhinitis - Post-infectious - Psychogenic cough	- Hemoptysis - Night sweats - Weight loss - Clubbing - Exercise intolerance
Adolescents (>12 years)	- Asthma - Habit cough - Smoking/vaping - Upper airway cough syndrome - Vocal cord dysfunction	- Hemoptysis - Systemic symptoms - Family history of CF/PCD - Absent during sleep - Digital clubbing

Differential Diagnosis by Cough Characteristics

Cough Type	Conditions	Associated Features
Barking/Croupy	- Croup (laryngotracheobronchitis) - Tracheitis - Tracheomalacia	- Inspiratory stridor - Worse at night - Hoarseness - Positional changes
Paroxysmal with/without whoop	- Pertussis - Parapertussis - Mycoplasma infection - Chlamydia pneumoniae	- Prolonged episodes - Post-tussive vomiting - Absence of fever - Inspiratory "whoop"
Staccato	- Chlamydia pneumoniae - Mycoplasma - Chlamydia trachomatis (infants)	- Series of short coughs - Afebrile pneumonia - Infants: tachypnea, rales
Chronic Wet/Productive	- Bronchiectasis - Cystic fibrosis - Primary ciliary dyskinesia - Protracted bacterial bronchitis	- Persistent sputum production - Recurrent infections - Failure to thrive - Digital clubbing
Nocturnal	- Asthma - Sinusitis/post-nasal drip - GERD - Heart failure	- Worsens when lying down - Associated with sleep disruption - May have daytime symptoms - Positional changes
Exercise-Induced	- Exercise-induced bronchoconstriction - Vocal cord dysfunction - Asthma	- Triggered by physical activity - Associated wheeze - Improves with rest - May have stridor (VCD)
Habit/Psychogenic	- Tic disorder - Psychogenic cough - Somatic cough syndrome	- Absent during sleep - Disappears with distraction - Honking quality - No organic findings

Laboratory and Diagnostic Studies

Consider these studies based on clinical presentation:

Investigation	Clinical Utility	When to Consider
Chest X-ray	Identify pneumonia, foreign body, anatomic abnormalities	Persistent cough, focal findings, systemic symptoms
Spirometry	Assess for obstruction, restriction, reversibility	Age >5-6 years, suspected asthma, chronic cough
Sweat Chloride Test	Diagnose cystic fibrosis	Chronic productive cough, failure to thrive, family history
Nasopharyngeal PCR	Identify viral or bacterial pathogens	Suspected pertussis, RSV, influenza, parainfluenza
PPD/IGRA	Screen for tuberculosis	TB exposure, chronic cough, risk factors, endemic region
Allergy Testing	Identify allergen triggers	Seasonal pattern, associated rhinitis, family history
Sputum Culture	Identify bacterial pathogens	Productive cough, suspected chronic infection

Advanced Studies

Reserve for specific indications or when diagnosis remains unclear:

Investigation	Clinical Utility	When to Consider
Bronchoscopy	Direct visualization of airways, specimen collection	Suspected foreign body, airway anomaly, refractory cough
High-resolution CT	Detailed airway and parenchymal assessment	Suspected bronchiectasis, interstitial disease, vascular anomalies
Barium Swallow	Evaluate for aspiration, TEF, anatomic anomalies	Cough associated with feeding, recurrent aspiration
pH/Impedance Study	Diagnose GERD, correlate with symptoms	Suspected reflux-associated cough, nocturnal symptoms
Ciliary Biopsy	Diagnose primary ciliary dyskinesia	Chronic wet cough, recurrent otitis/sinusitis, situs inversus
Immune Workup	Evaluate for immunodeficiency	Recurrent infections, failure to thrive, family history
Echocardiogram	Assess cardiac structure and function	Suspected vascular ring, heart failure, pulmonary hypertension

Diagnostic Algorithm

A stepwise approach to evaluating cough in children:

1. Classify cough duration (acute, subacute, chronic)
2. Assess for specific cough pointers indicating likely diagnosis
3. Evaluate for red flags requiring urgent attention
4. Initial testing based on clinical suspicion:
   • Acute: Usually minimal testing unless severe
   • Subacute: Consider CXR if not improving
   • Chronic: CXR, spirometry (if age-appropriate)
5. Trial of targeted therapy based on most likely diagnosis
6. Response assessment and additional testing if needed
7. Consider referral for specialized testing for persistent symptoms
8. Periodic reassessment to monitor for evolution of symptoms

Management Strategies

General Approach to Management

Key principles in managing pediatric cough:

• Identify and treat underlying cause: Targeted therapy based on diagnosis
• Supportive care: Hydration, humidification, position optimization
• Education: Counseling on expected course and warning signs
• Monitoring: Follow-up to ensure resolution or appropriate response to therapy
• Preventive measures: Reduce exposures, optimize management of underlying conditions

Non-Pharmacological Interventions

Intervention	Description	Evidence Level
Hydration	- Maintain adequate fluid intake - Warm clear liquids for soothing effect - Age-appropriate hydration goals	Moderate; physiological basis, limited formal studies
Humidity	- Cool mist humidifier in bedroom - Warm steam shower for temporary relief - Avoid over-humidification (>50%)	Low to moderate; conflicting evidence, but physiologically sound
Positioning	- Elevate head of bed (older children) - Avoid flat position with GERD/post-nasal drip - Upright positioning during acute episodes	Low to moderate; based on pathophysiology, limited studies
Environmental Modifications	- Avoid smoke exposure - Reduce allergen exposure - Air purification - Dust control measures	Moderate to high; strong evidence for smoke reduction, variable for others
Honey (>1 year of age)	- 2.5-10 mL based on age - Given before bedtime - May repeat if needed	Moderate; several RCTs show benefit for nocturnal cough

Pharmacological Management by Diagnosis

Diagnosis	First-line Treatment	Alternative Approaches	Duration/Follow-up
Viral Upper Respiratory Infection	- Supportive care - Hydration - Consider honey (>1 year)	- Nasal saline - Nasal suctioning for infants - Humidification	- Self-limited, typically 7-14 days - Follow-up if >2 weeks - Return if worsening symptoms
Asthma/Reactive Airway Disease	- Short-acting β-agonist (acute) - Inhaled corticosteroids (persistent) - Combination therapy if indicated	- Leukotriene modifiers - Oral corticosteroid bursts (exacerbations) - Environmental control	- Follow-up in 2-4 weeks after initiation - Adjust therapy based on control - Regular monitoring of growth, symptoms
Croup	- Dexamethasone 0.6 mg/kg (single dose) - Cool mist - Calm environment	- Nebulized epinephrine (moderate-severe) - Repeated steroid dose if symptoms recur - Hospitalize if respiratory distress	- Most improve within 24-48 hours - Follow-up for recurrent episodes - Return for increased work of breathing
Bronchiolitis	- Supportive care - Hydration - Nasal suctioning as needed	- Hypertonic saline (hospitalized) - Consider oxygen if hypoxemic - High-flow nasal cannula if indicated	- Expected course 1-2 weeks - Follow-up in 24-48 hours for infants - Monitor for feeding difficulties
Bacterial Pneumonia	- Amoxicillin (standard dose) - Amoxicillin-clavulanate if aspiration risk - Azithromycin if atypical suspected	- Ceftriaxone (hospitalized) - Clindamycin (penicillin allergy) - Combination therapy if complicated	- 7-10 days of antibiotics - Follow-up in 48-72 hours - CXR follow-up for complicated cases
Pertussis	- Azithromycin x 5 days - Supportive care - Close monitoring in infants	- Clarithromycin - TMP-SMX (>2 months) - Hospitalize young infants	- Contagious period ends after 5 days of antibiotics - Cough may persist 6-10 weeks - Prophylaxis for close contacts
Protracted Bacterial Bronchitis	- Amoxicillin-clavulanate (2 weeks) - Chest physiotherapy if indicated - Airway clearance techniques	- Extended course (4 weeks) if recurrent - Alternative antibiotics based on culture - Investigate for underlying conditions	- Follow-up after 2 weeks - Consider extended treatment if partial response - Bronchoscopy if >3 episodes/year
Upper Airway Cough Syndrome (Post-nasal Drip)	- Nasal saline irrigation - Intranasal corticosteroids - Antihistamines if allergic component	- Short course decongestants (brief use) - Antibiotics if acute sinusitis - Allergen avoidance	- 2-4 weeks for initial treatment - Long-term management for allergic rhinitis - Follow-up if no improvement
GERD-associated Cough	- Lifestyle modifications - Thickened feeds (infants) - Trial of PPI (4-8 weeks)	- H2 blockers - Prokinetic agents (limited evidence) - Evaluation for complications	- Reassess after 4-8 weeks - Consider weaning if improved - Further evaluation if refractory

Management of Specific Cough Scenarios

Scenario	Approach	Considerations
Acute Cough (<2 weeks)	- Symptomatic relief - Targeted therapy if specific diagnosis - Reassurance about expected course	- Most self-limited - Red flags: respiratory distress, dehydration, toxic appearance - Lower threshold for evaluation in infants
Chronic Cough (>4 weeks)	- Systematic evaluation - Empiric treatment trials (sequential) - Referral if persistent or concerning features	- Consider anatomic, inflammatory, infectious causes - Document response to interventions - Quality of life assessment important
Recurrent Cough (multiple episodes)	- Identify triggers - Pattern recognition - Maintenance therapy for underlying condition	- Diary to document patterns - Consider seasonal allergies, viral triggers - Evaluate for asthma even between episodes
Refractory Cough	- Multidisciplinary approach - Revisit diagnosis - Consider rare conditions	- Adherence assessment - Environmental assessment - Psychological factors
Habit/Psychogenic Cough	- Avoid reinforcing behavior - Distraction techniques - Behavioral therapy	- Diagnosis of exclusion - Avoid excessive medical interventions - Address underlying anxiety or stress

Over-the-counter Cough Medications

Generally not recommended for children:

Medication Type	Considerations	Recommendations
Antitussives (Dextromethorphan)	- Limited efficacy data - Safety concerns under 4 years - Potential for misuse	- Not recommended <6 years - Avoid in children <4 years - Limited evidence of benefit
Expectorants (Guaifenesin)	- Theoretical mechanism - Limited pediatric efficacy data - Generally safe profile	- Not recommended <4 years - Limited evidence for efficacy - Hydration preferred approach
Antihistamine/Decongestant Combinations	- Anticholinergic side effects - Paradoxical excitation - Limited efficacy for cough	- Not recommended in young children - Avoid for cough without allergic component - Risk outweighs benefit
Menthol/Camphor Products	- Topical application only - Risk of toxicity if ingested - Potential for respiratory depression	- Avoid in children <2 years - Use with caution in older children - Keep away from face and nostrils

When to Refer

• Pulmonology: Chronic cough >4 weeks without diagnosis, suspected cystic fibrosis, bronchiectasis, recurrent episodes
• ENT: Suspected foreign body, anatomical abnormalities, recurrent croup, stridor
• Allergy/Immunology: Suspected immunodeficiency, refractory allergic disease, recurrent infections
• Gastroenterology: Suspected aspiration, refractory GERD, feeding difficulties with respiratory symptoms
• Cardiology: Suspected vascular ring, heart failure, cough with exercise intolerance
• Emergency Department: Respiratory distress, cyanosis, severe stridor, dehydration, toxic appearance

Prevention Strategies

• Immunizations: Routine vaccines including influenza, pneumococcal, pertussis
• Environmental control: Tobacco smoke avoidance, allergen reduction, indoor air quality
• Infection control: Hand hygiene, avoiding sick contacts, proper cough etiquette
• Optimal management: Good control of underlying conditions (asthma, allergies, GERD)
• Nutrition and hydration: Adequate fluid intake, proper feeding techniques to prevent aspiration

Family Education

• Expected course: Natural history of common causes
• Warning signs: When to seek urgent medical attention
• Home management: Appropriate supportive care techniques
• Medication administration: Proper technique for inhalers, nasal sprays
• Prevention: Reducing risk factors