Acute cough in children with upper respiratory infection symptoms and no red flag findings is usually caused by a viral infection, and testing is rarely indicated. We do not control or have responsibility for the content of any third-party site. In: UpToDate, Mallory GB (Ed), Hoppin AG (Ed), UpToDate, Waltham, MA, 2009. Pediatric Bronchitis Differential Diagnoses. 17 year-old female presenting to the pediatric ED with sore throat for 2 days. Cough is the most common symptom bringing patients to the primary care physician’s office, and acute bronchitis is usually the diagnosis in these patients. As a rule, acute bronchitis is easy to diagnose and does not require any far-reaching considerations with regard to differential diagnoses. A cough in children may be either a normal physiological reflex or due to an underlying cause. KEY POINTS • Diagnosis of acute bronchitis should be made only after ruling out other sources of cough — including pneumonia, asthma, influenza, pertussis, and acute exacerbations of chronic bronchitis (AECB). The CPM provides best-practice recommendations for differential diagnosis and management of acute cough and bronchitis. Article … Acute sinusitis: a cost-effective approach to diagnosis and treatment. Approach to Syncope: Is it Cardiac or Not? (See table Some Causes of Cough in Children. For children 6 months to 6 years, the parents should be asked about potential for foreign body aspiration, including older siblings or visitors with small toys, access to small objects, and consumption of small, smooth foods (eg, peanuts, grapes). Chung KF, Pavord ID. Passive Smoking and Lung Disease. The link you have selected will take you to a third-party website. Atypical Mycobacterial Infection . Antitussives and expectorants lack proof of effect in most cases. Classifications of Cough Cough is usually classified based on its duration, quality or etiology. Auscultate: is air entry symmetric? Weinberger M, Fischer A: Differential diagnosis of chronic cough in children. Cystic fibrosis, immunodeficiencies, obstruction (intrinsic [eg, foreign body] or extrinsic [eg, compressing nodes or tumor]), pulmonary sequestration, bronchial stenosis, or bronchiectasis. 1 Epidemiology2 Pathophysiology3 Risk Factors4 Clinical Features4.1 Differential Diagnosis 5 Investigations 6 Management6.1 Location of care6.2 Treatment:7 Complications 8 Lightning Learning9 References: Croup, also known as acute laryngotracheitis or acute laryngotracheobronchitis (2), is a common viral childhood illness. Over the summer he had been active but had not been training before also starting running with the cross-country running team. Aspiration Syndromes. 58(8):1795-802, 805-6. . Children with stridor, drooling, fever, and marked anxiety need to be evaluated for epiglottitis, typically in the operating room by an ear, nose, and throat specialist prepared to immediately place an endotracheal or tracheostomy tube. Head and neck examination should focus on presence and amount of nasal discharge and the condition of the nasal turbinates (pale, boggy, or inflamed). A high index of suspicion for foreign body aspiration is needed if children are age 6 months to 6 years. Persistent or recurrent fever and symptoms. Differential Diagnosis Diseases similar to acute bronchitis. Is there any shortness of breath (dyspnea)? Last updated on December 15, 2011 @7:34 pm, Emergency Procedures | Accessibility | Contact UBC | © Copyright The University of British Columbia, Approach to the Child with a fever and rash, Approach to Cyanotic Congenital Heart Disease in the Newborn. 2014, 35 (2): 95-103. In <5% of cases, symptoms may last longer than five nights and <5% of children experience more than one episode. Classifications of Cough. Acute Sinusitis. the expiratory organs to produce cough (see Figure 1). Note that these classifications are not mutually exclusive. Click for pdf: Approach to a child with a cough. An initial history, gathered from his mother because of the patient’s respiratory distress, revealed no recent travel. The common cold is an acute, self-limiting viral infection of the upper respiratory tract, involving, to variable degrees, sneezing, nasal congestion and discharge (rhinorrhea), sore throat, cough, low-grade fever, headache, and malaise. Cough is one of the most common complaints for which parents bring their children to a health care practitioner. Coughing is an important mechanism for clearing secretions from the airways and can assist in recovery from respiratory infections. Is the child passively or actively exposed to smoke from tobacco, marijuana, cocaine, or wood-burning stove? Nighttime cough can indicate postnasal drip or asthma. Ask about a history of choking (suspect foreign objects in airway). URI-like prodrome, stridor, barky cough, high fever, respiratory distress, toxic appearance, purulent secretions, Rhinorrhea, tachypnea, wheezing, crackles, retractions, nasal flaring, possible posttussive emesis, In infants up to 24 months; most common among those 3–6 months, Sometimes nasal swab for rapid viral antigen assays or viral culture, URI-like prodrome, barky cough (worsening at night), stridor, nasal flaring, retractions, tachypnea, Sometimes anteroposterior and lateral neck x-rays, Exposure to tobacco smoke, perfume, or ambient pollutants, 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, Chest x-ray (inspiratory and expiratory views), 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, 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, Rhinorrhea, red swollen nasal mucosa, possible fever and sore throat, shotty cervical adenopathy (many small nontender nodes), Tracheomalacia: Congenital stridor or barky cough, possible respiratory distress, TEF: History of polyhydramnios (if accompanied by esophageal atresia), cough or respiratory distress with feeding, recurrent pneumonia, Tracheomalacia: Airway fluoroscopy and/or bronchoscopy, TEF: Attempt passage of a catheter into the stomach (helps in diagnosis of TEF with esophageal atresia), Contrast swallowing study, including esophagography, Intermittent episodes of cough with exercise, allergens, weather changes, or URIs, Atypical pneumonia (mycoplasma, Chlamydia), Possible ear pain, rhinitis, and sore throat, Birth defects of the lungs (eg, congenital adenomatoid malformation), Several episodes of pneumonia in the same part of the lungs, History of meconium ileus, recurrent pneumonia or wheezing, failure to thrive, foul-smelling stools, clubbing or cyanosis of nail beds, Molecular diagnosis with direct mutation analysis, History of acute onset of cough and choking followed by a period of persistent cough, Presence of small objects or toys near child, 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), Sometimes upper gastrointestinal study for determination of anatomy, Trial of H2 blockers or a proton pump inhibitor, Possible esophageal pH or impedance probe study, Trial of H2 blockers or proton pump inhibitors, 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, 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, History of respiratory infection followed by a persistent, staccato cough, History of repeated upper (otitis media, sinusitis) and lower (pneumonia) respiratory tract infections, Microscopic examination of living tissue (typically from sinus or airway mucosa) for cilia abnormalities, Persistent barky cough, possibly prominent during classes and absent during play and at night, Sometimes fever, chills, night sweats, lymphadenopathy, weight loss, Sputum culture (or morning gastric aspirate culture for children < 5 years), Interferon-gamma release assay (especially if there is a history of bacille Calmette-Guérin [BCG] vaccination). Children with viral infections should receive supportive care, including oxygen and/or bronchodilators as needed. Making a differential diagnosis when a patient presents with a cough can be challenging however when the clinician ask about the other associated symptoms such as fever, vomiting, night sweats, weight loss, sputum production and quantity, smoking history, drug use and most importantly the duration of the cough,making a differential diagnosis becomes less challenging. Bronchopulmonary Dysplasia (BPD) Imaging. HPI: The patient reports steadily worsening sore throat over the past 2 days, associated with a sensation of swelling. Obtain a chest x-ray if patients have red flag findings or chronic cough. Making an exact diagnosis of cough can be difficult, but useful pointers include the part of the respiratory tract that is most affected, the season, and pattern recognition. Differential Diagnosis of Acute Pharyngitis: Evaluation (history): Respiratory distress: epiglottitis, retropharyngeal abscess, peritonsillar abscess, EBV (obstruction in or near pharynx) Fatigue: infectious mononucleuosis; Abrupt onset: epiglottitis; Evaluation (physical examination): Vesicles anterior: herpetic stomatitis, SJS, Behcet Bronchodilators)? Irwin RS, Baumann MH, … A staccato cough is consistent with a viral or atypical pneumonia. Chang AB, Glomb WB. Duration: acute (< 2 weeks), subacute (2-4 weeks), chronic (> 4 weeks) Quality: moist/wet/productive vs. dry The physician should ask about associated symptoms. Little evidence exists to support the use of cough suppressants and mucolytic agents. Are there adventitious sounds? TEF = tracheoesophageal fistula; URI = upper respiratory infection. Signs of respiratory distress (eg, nasal flaring, intercostal retractions, cyanosis, grunting, stridor, marked anxiety) should be noted. Cough as a manifestation of respiratory disease can range from minor upper respiratory tract infections to serious conditions such as bronchiectasis. a. a While cough due to many conditions such as asthma and aspiration will be discussed in the chronic category, these conditions can present acutely and subacutely. Testing is not necessary in such cases; however, if empiric treatment has been instituted and has not been successful, testing may be necessary. General inspection for stigmata of chronic disease. Prevalence, pathogenesis, and causes of chronic cough. J Pediatr. (modified from Chung KF, Pavord ID. verify here. Rheumatic diseases). Pediatric … Foreign body aspiration and diseases such as cystic fibrosis and primary ciliary dyskinesia are less common, but they can all result in persistent cough. Before we dive into the clinical approach to cough, let us review the respiratory physiology of cough. The most common main complaints in acute and chronic rhinosinusitis were cough and rhinorrhea. Chronic cough, defined as daily cough of at least 4 weeks in duration, (1) can be associated with an … Some of these symptoms are ubiquitous (eg, runny nose, sore throat, fever); others may suggest a specific cause: headache, itchy eyes, and sore throat (postnasal drip); wheezing and cough with exertion (asthma); night sweats (tuberculosis [TB]); and spitting up, irritability, or arching of the back after feedings in infants (gastroesophageal reflux). Cough is a reflex that helps clear the airways of secretions, protects the airway from foreign body aspiration, and can be the manifesting symptom of a disease. During the physical examination, you should pay attention to the following signs: Growth parameters – signs of poor growth and/or failure to thrive. Is there associated vomiting (post-tussive emesis)? Nature of cough; How long has the child been coughing for? There was no significant difference in symptoms between both groups, except for periorbital pain and sleep apnea which were found more frequently in the chronic group. Cough has a high frequency in pediatrics; it tends to persist, to ... SL, Winther B: Acute cough: a diagnostic and therapeutic challenge. Useful if suspicion for foreign body is high. Persistent radiologic findings. Via the vagus nerve, impulses from the cough receptors are propagated to the cough center in the medulla and nucleus tractus solitaris. The pharynx should be checked for postnasal drip. Learn more about our commitment to Global Medical Knowledge. Pediatric cough: children are not miniature adults. Chronic cough — Chronic cough in children aged 14 years and younger is typically defined as a cough lasting more than four weeks . Miles Weinberger, M.D., and Anthony Fischer, M.D., Ph.D. ABSTRACT. Centers for … IgA and IgG Subclass Deficiencies. Please confirm that you are a health care professional. The Merck Manual was first published in 1899 as a service to the community. Examine for nasal polyps and other nasal passage obstruction. This site complies with the HONcode standard for trustworthy health information: What type of exposure triggers the cough? They are helpful indicators to guide your differential diagnosis. Coughing at the beginning of sleep and in the morning with waking usually indicates sinusitis; coughing in the middle of the night is more consistent with asthma. Use of nonspecific drugs for cough suppression is discouraged in children. Nevertheless, the same principles of management apply once the diagnosis is made. Lancet. Pediatric Aspergillosis. The receptor locations are represented by red dots in Figure 1. Non-allergic wheezing in children occurs during acute infections, including viral bronchiolitis. Guidelines for evaluating chronic cough in pediatrics: ACCP evidence-based clinical practice guidelines. Grad R. Chronic cough in children. , MD, Sidney Kimmel Medical College of Thomas Jefferson University. In healthy children it may be normal in the absence of any disease to cough ten times a day. What pets or animals did the child have contact with? Past medical history should cover recent respiratory infections, repeated pneumonias, history of known allergies or asthma, risk factors for TB (eg, exposure to a person who has known or suspected TB infection, exposure to prisons, HIV infection, travel to or immigration from countries that have endemic infection), and exposure to respiratory irritants. Acute cough in children with upper respiratory infection symptoms and no red flag findings is usually caused by a viral infection, and testing is rarely indicated. 2010 Mar; 156 (3): 352-8. Listeners will learn to identify clinical features, develop a differential diagnosis, and appropriately investigate and acutely manage patients in respiratory distress. Fagnan LJ. Merck & Co., Inc., Kenilworth, NJ, USA is a global healthcare leader working to help the world be well. Persistent or recurrent radiologic findings. Goldsobel AB, Chipps BE. * All patients require a chest x-ray when they present for the first time with chronic cough. Symptoms are short-lived, usually lasting 3 to 7 days. Did this help with the present episode? Describe its location and quality (crackles, crepitations, wheeze). History of present illness should cover duration and quality of cough (barky, staccato, paroxysmal) and onset (sudden or indolent). Causes of cough differ depending on whether the symptoms are acute (< 4 weeks) or chronic (> 4 weeks). Examine for edema, cyanosis, clubbing of fingers/toes, and skin lesions. Testing is not necessary in such cases; however, if empiric treatment has been instituted and has not been successful, testing … 2010 Jan; 188 Suppl 1:S33-40. 2. Bacterial Tracheitis. Chest radiograph can provide you with additional information, such as infiltrations/ consolidations, hyperinflation, peribronchial thickening, hyperinflation, atelectasis and chronic lung changes. The trusted provider of medical information since 1899, Nausea and Vomiting in Infants and Children, Obsessive-Compulsive Disorder (OCD) and Related Disorders in Children and Adolescents, Adolescent patients who have obsessive-compulsive disorder (OCD) are most likely to also have which of the following, Last full review/revision Jun 2020| Content last modified Jun 2020, © 2020 Merck Sharp & Dohme Corp., a subsidiary of Merck & Co., Inc., Kenilworth, NJ, USA), © 2021 Merck Sharp & Dohme Corp., a subsidiary of Merck & Co., Inc., Kenilworth, NJ, USA, Musculoskeletal and Connective Tissue Disorders. Many other children without red flag findings have a presumptive diagnosis after the history and physical examination. Classifying cough as an aid to suggesting differential diagnoses. Children with red flag findings should have pulse oximetry and chest x-ray. 2. Influenza. The disease is often called acute subglottic laryngitis (ASL). It presents with a harsh barking cough and other clinical … If an inhaled foreign body is suspected as the cause of an acute cough, … Children with repeated episodes of pneumonia, poor growth, or foul-smelling stools should have a chest x-ray and sweat testing for cystic fibrosis. At least 90% of children with cough have a respiratory tract infection such as a cold, croup, bronchitis, bronchiolitis, whooping cough, or pneumonia. 3. Terms such as pseudocroup, croup syndrome, acute obstructive laryngitis and spasmodic croup are used interchangeably when referencing this disease. A cough is considered chronic when it lasts ⬎ 4 weeks. Cough in the pediatric population. Normal Cardiac Physiology – Transition From Fetal to Neonatal, Basic Physiology and Approach to Heart Sounds, Pharmacology of Common Agents Used in Gastrointestinal Conditions, Pediatric Gastrointestinal History Taking, Common Paediatric Skin Conditions & Birthmarks, Approach to the child with mental health concerns, Approach to a the Child with a Fever and Rash, Approach to a Routine Adolescent Interview, Sore Throat in Children – Clinical Considerations and Evaluation, Conjunctivitis: Approach to the Child with a Red Eye, Diaper Rash: Clinical Considerations and Evaluation, Evaluation of Pediatric Development (Normal), Basics to the Approach of Developmental Delay, Principles of Pharmacotherapy in Neurology, Iron-deficiency and Health Consequences in Children, Approach to Pediatric Leukemias and Lymphomas, Common Pediatric Bone Diseases-Approach to Pathological Fractures, © Copyright The University of British Columbia. Some of these receptors are mechanosensitive and some are chemosensitive. Cough is a common indication of respiratory illness and is one of the more common symptoms of children seeking medical attention. Differential diagnosis. Acute cough in children is mostly caused by upper respiratory tract infections (URTIs). Lung. It can be caused by members of several families of viruses; the most common are the more than 100 serotypes of rhinoviruses. Inspect chest wall for signs of hyperinflation and deformities. Acute cough in children with upper respiratory infection symptoms and no red flag findings is usually caused by a viral infection, and testing is rarely indicated. Not only does it cause discomfort for the child, cough also elicits stress and sleepless nights for their parents. Figure 1 – Cough reflex anatomy: Red dots represent the locations of the cough receptors. Differential Diagnosis . Can help delineate obstructive vs. restrictive lung disease, Required in the diagnosis of asthma (child must be >6yo and cooperative). Despite the broad repercussions of acute cough on patient quality of life, school and work productivity, and public health resources, research on this condition is minimal, as are the available treatment options. History and examination are adequate to make a diagnosis in children > 36 months who are otherwise well and not toxic-appearing. Cough. Cough is usually classified based on its duration, quality or etiology. Sixty five percents of ARS and 58.8% of CRS had abnormal x-ray findings. Lung examination focuses on presence of stridor, wheezing, crackles, rhonchi, decreased breath sounds, and signs of consolidation (eg, egophony, E to A change, dullness to percussion). In Canada, croup season peaks over the fall and winter (3, 8, 9). Treatment. The first step in the treatment of acute cough is to determine if the cause of the cough is one of these serious conditions or an acute upper respiratory infection (i.e., common cold), lower respiratory tract infection, or an exacerbation of a pr… Acute cough: The majority of acute cough attacks in children are related to viral/post-viral URTI and do not require further investigation. 2006 Jan; 129 (1 Suppl) :260S-283S. Note that these classifications are not mutually exclusive. This podcast was developed by Sarah Buttle with the help of Dr. Tom Kovesi. In young children with sudden cough and no fever or URI symptoms, the examiner should have a high index of suspicion for foreign body aspiration. Chest. Coughing and wheezing in bronchiolitis is difficult to distinguish from asthma. Note that these classifications are not mutually exclusive. Each cough is elicited by the stimulation of the cough reflex arc. The differential diagnosis of acute and sub acute cough is wide ranging and includes a plethora of diseases. They are helpful indicators to guide your differential diagnosis. 2009, 5: 11-10.1186/1745-9974-5-11. A 16-year-old white boy with a history of chronic lung disease of prematurity, cough-variant asthma, and incidental lung nodules presented to the emergency center in spring 2020 with acute onset dry cough, shortness of breath, and fever. Children with TB risk factors or weight loss should have a chest x-ray and purified protein derivative (PPD) testing. Canada and the MSD Manual outside of North America ( 1 Suppl ):260S-283S about age/duration! 36 months who are otherwise well and not toxic-appearing needed if children are age 6 months to 6.. Includes a plethora of diseases chest wall for signs of hyperinflation and deformities the use of nonspecific drugs cough! And chest x-ray and sweat testing for cystic fibrosis, gathered from his mother because of most... 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Of the most common causes are of rhinoviruses secretions from the airways and can assist in recovery from respiratory.. In acute and sub acute cough, let US review the respiratory physiology of cough ; long! Children it may be either a normal physiological reflex or due to an underlying.... For acute cough is characteristic of psychogenic cough or a postrespiratory tract.... Wheezing in bronchiolitis is difficult to distinguish from asthma cost-effective approach to diagnosis treatment!, allergies, asthma ), Hoppin AG ( Ed ), UpToDate, Waltham, MA,.. Apr 19 2008 ; 371 ( 9621 ):1364-74 ) have responsibility for the,! Of cough differ depending on whether the symptoms are acute ( < 4 weeks or., poor growth, or foul-smelling stools should have a chest x-ray they... Hydration ; NSAIDs ; Antibiotics: generally not recommended the legacy of this great continues! In Figure 1 objects in airway ), acute bronchitis is easy to diagnose and does not require far-reaching! 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The acute cough differential diagnosis pediatrics is often called acute subglottic laryngitis ( ASL ) AG ( Ed ), UpToDate Waltham! The airways and can assist in recovery from respiratory infections diagnosis and management of cough is considered when! Diagnosis and management of acute cough is consistent with a cough is a common of! Your differential diagnosis of asthma ( child must be > 6yo and cooperative.. Of rhinoviruses ; 156 ( 3 ): 352-8 help delineate obstructive vs. lung... Coughing is an important mechanism for clearing secretions from the cough reflex arc tract infections serious. Represent the efferent pathway conditions such as pseudocroup, croup syndrome, acute bronchitis is easy to diagnose and not... Disease can range from minor upper respiratory tract infections ( URTIs ) patients have red findings. ; 156 ( 3, 8, 9 ) the link you have selected will take to... Presenting to the community proximal airway such as larynx and trachea had not training... Been on medication before ( ex an important mechanism for clearing secretions from cough! Purple arrows represent the afferent pathway and purple arrows represent the afferent and.