IIA&Cough&in&Children&

Cough:! ! ! Under!both!Voluntary!&!Involuntary!control!
! ! ! ! Clear!Airways!of!Secretions!
! ! ! ! ! Primary!mechanism!for!Secretion!Removal!when!Resp!Cilia!are!damaged!by!Inflammation!
! ! ! ! Cough!Reflex!protect!airway!following!Inhalation!of!Foreign!material!(food,!secretions,!etc)!
! ! ! ! Cough!receptors!located!within!Epithelium!of!Pharynx,!Larynx,!Trachea!&!Major!Bronchi!
! ! ! ! ! Stimulated!Mechanically,!Chemically,!Thermally!
! ! ! ! ! Stimulated!by:! Local!mediators!(Histamine,!Prostaglandins,!Leukotrienes)!
! ! ! ! ! ! ! ! Local!Bronchoconstriction!
! ! ! ! Reflex!arc:!! Afferent!fibres!from!Vagus!nerve!to!Cough!centre!in!Upper!Brainstem!
! ! ! ! ! ! ! Efferent!fibres!from!Vagus!nerve!&!SC!to!Larynx,!Diaphragm!&!Abd!muscles!
! ! ! ! Higher!Cortical!control!of!Visceral!Reflex:! Cough!Inhibition!&!Voluntary!Cough!
! ! ! ! Cough!receptors!also!in!Pharynx,!Paranasal!sinuses,!Stomach!&!EAC!
! ! ! ! ! Source!of!Persistent!Cough!may!Not!be!in!Lungs!
Cause:!
! Resp:! ! URTI,!! ! ! ! ! Postnasal!Drip!syndrome!(Upper!airway!Cough!syndrome),!
! ! ! ! Asthma,! ! ! ! ! Aspiration,!
! ! ! ! Pneumonia/Pneumonitis,! ! Bronchiectasis!
! NonTResp:!! HF,! ! ! ! ! ! GER,!
! ! ! ! ACEI,!! ! ! ! ! Psychogenic/Habit!Cough!
Hx!for!Childhood!Cough:!
! Who:! ! Age!
! ! ! ! Previous!Health:! ! ! Community!vs!Hospital!acquired!
! ! ! ! IC!state/HIVTinfected?:! ! Opportunistic!
! ! ! ! Neurologically!impaired?:! ! Aspiration!Pneumonia!from!Swallowing!Incoordination!
! ! ! ! Atopic?:! ! ! ! ! Asthma,!Postnasal!drip!
! ! ! ! Living!at!home?!Institution?:! CommunityTacquired!
! What!Cough:! Dry?:!! ! ! ! ! Mycoplasma,!Psychogenic,!Asthma!
! ! ! ! Productive?:! ! ! ! Pneumonia,!Bronchiectasis!
! ! ! ! Blood!stained?:!! ! ! Pneumonia,!Bronchiectasis,!TB,!Excoriated!airway!
! ! ! ! Barking?!Brassy?:! ! ! Croup!
! ! ! ! Wheezy?:! ! ! ! ! Asthma,!Acute!Bronchiolitis!
! ! ! ! Paroxysmal?!
! How!Long:!! Most!common!Stimulus!of!Cough:! Irritation/Inflammation!of!Resp!Epithelium!
! ! ! ! Acute!vs!Subacute!vs!Chronic!
! ! ! ! Acute!Cough:! Recent!onset!of!Cough!lasting!<3!weeks!
! ! ! ! ! ! ! Viral!URTI!account!for!most!Acute!Cough!at!All!Ages!
! ! ! ! ! ! ! SelfTlimiting!
! ! ! ! ! ! ! Usually!last!1T3!weeks!
! When!occur:! After!Feeding?:!! ! ! ! GER!
! ! ! ! Middle!of!the!Night?:!! ! ! Asthma,!Sinusitis!

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! ! ! ! When!Weather!change!&!turn!Cold?:!Asthma!
! ! ! ! When!someone!Smoke?!
! ! ! ! With!Exertion?:!! ! ! ! HF,!Asthma!
! ! ! ! Soon!after!lying!down?:! ! ! Postnasal!drip!
! ! ! ! Associated!with!Fever?:! ! ! Infection!
! ! ! ! Associated!with!Runny!nose?!
! ! ! ! When!Nervous?!Resolve!with!Sleep?:!Psychogenic/Habitual!Cough!
PE:! ! ! ! Temp!(Fever)!
! ! ! ! Vital!signs!
! ! ! ! Resp!distress?:! ! RR,!Retraction/Insucking/Use!of!Accessory!muscles,!Cyanosis,!Dyspnea!
! ! ! ! Chest!Exam:! ! Deformity,!Percussion,!Auscultation!(Wheeze,!Crepitations,!Rhonchi)!
! ! ! ! Associated!finding:! Skin!Rash,!Eczema,!Tonsils,!LN,!Rhinorrhea!
Acute!Cough:! ! Acute!infection:!
! ! ! ! ! URI:! Viral:!! Influenza,!RSV,!Parainfluenza,!Adenovirus,!Rhinovirus,!
! ! ! ! ! ! ! ! Human!Coronavirus,!Human!Metapneumovirus,!Bocavirus!
! ! ! ! ! ! ! ! (Bocavirus!need!PCR;!Not!routinely!checked)!
! ! ! ! ! LRI:! Viral!
! ! ! ! ! ! Bacterial:! Streptococcus!pneumoniae,!Haemophilus!influenzae,!
! ! ! ! ! ! ! ! Pseudomonas!if!IC,!Chlamydia!if!Neonate!
! ! ! ! Exacerbation!of!PreTexisting!condition:!
! ! ! ! ! Asthma,!Bronchiectasis,!Upper!airway!Cough!syndrome!(Postnasal!drip)!
! ! ! ! Hx!&!PE!
! ! ! ! Absence!of!Fever,!Tachypnea!&!Chest!signs:! Most!useful!for!ruling!out!LRT!involvement!
! ! ! ! Most!Children!with!Cough!due!to!a!simple!URI!do!Not!need!any!Ix!
! ! ! ! CXR!should!be!considered!in!presence!of:!
! ! ! ! ! LRT!signs!(+/–)!
! ! ! ! ! Relentlessly!Progressive!Cough!
! ! ! ! ! Hemoptysis/Undiagnosed!Chronic!Resp!disorder!
! ! ! ! ±!Other!Ix!depending!on!your!ddx:!
! ! ! ! ! CBC!&!DC,!NPA!for!common!viruses,!Sputum!for!Gram!stain!&!Culture!if!Pt!Old!enough,!
! ! ! ! ! Blood!Culture!(though!Low!detection!rate)!
! Approach:!!
Question! Features! Likely!common!Dx!
Acute!URI?! Coryzal!Sx,!Fever,!Sore!throat! URI!
Croup!syndrome?! Stridor,!`Barking’/`Croupy’!Cough,!Hoarseness,!±! Viral!Croup,!Recurrent!Spasmodic!
Fever! Croup,!Bacterial!Tracheitis!
LRT!illness?! Tachypnea!(>60!for!<2m,!>50!for!2T12m,!>40!for! Acute!Bronchiolitis,!Pneumonia!
>1!year),!Resp!distress!with!↑Work!of!Breathing,! (Viral,!Bacterial),!Asthma!
Chest!Signs!(Crackles!or!Wheeze/Rhonchi),!Fever!
Allergic/Atopic!illness?! Seasonal!&!Diurnal!variation,!Association!with! Postnasal!drip!from!Allergic!

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Cough! in! Children!
 Rhinitis,!Posture!(Lie!down!–!Drip),!`Clearing!of! Rhinitis,!
Throat’,!Triggers!(Cold,!Dust,!Pollutant,!Pollen,!etc)! Reactive!airway/Asthma!
Acute!Exacerbation!of! Failure!to!Thrive,!Finger!Clubbing,!Chest!deformity,! !
Chronic!Resp!disorder?! Features!of!Atopy!
Chronic!Cough:!
! Definition:!
! ! American!College!of!Chest!Physician!Guideline!(Chest!2006):!
! ! ! ! Pediatric!(<15!yo)!Chronic!Cough:! Daily!Cough!lasting!for!>4!weeks!
! ! ! ! ! No!studies!that!clearly!define!
! ! ! ! ! Time!frame!chosen!due!to!Natural!Hx!of!URI!in!Children!(Lasting!1T3!weeks!in!Children)!
! ! ! ! ! ! 1!study:!10%!Preschool!Children!still!Coughing!25!days!after!URI!
! ! ! ! ! Different!from!Definition!in!Adults!
! ! British!Thoracic!Society!(Thorax!2007):!
! ! ! ! Cough!lasting!>8!weeks!
! ! ! ! Recognize!a!‘Grey’!area!of!‘Subacute!Cough’!between!2T8!weeks!
! ! NB:! ! Subdivided:! Specific!Cough:! ! Cough!with!S/S!suggestive!of!associated!problem!
! ! ! ! ! ! ! NonSpecific!Cough:! Dry!Cough!in!Absence!of!identifiable!known!etiology!
! Duration!of!Sx:! Rhinovirus!Colds!

! ! ! ! !
! ! ! ! Be!Specific!about!Duration!&!Intensity!–!May!mean!different!things!!

! ! ! ! !
! ! ! ! ! (Cough!for!3!weeks!can!be!improving!after!peak,!Progressive,!or!Recurrent;!Be!specific!)!
! Approach:!
Question! Examples! Ddx!
How!did! Very!Acute!or!After!Choking! Inhaled!Foreign!body!
Cough!start?! With!URI! PostTviral!Cough!

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Cough! in! Children!
 When!did! Neonatal!onset! Aspiration,!Congenital!malformation,!
Cough!start?! Cystic!Fibrosis,!PCD!
Quality!of! Productive!(Moist/Wet)! Chronic!Suppurative!disease!(eg.!
Cough?! Bronchiectasis)!
Paroxysmal!Spasmodic!Cough!±`Whoop’! Pertussis!
Hemoptysis! TB!in!Adolescents,!Bronchiectasis,!AVM!
(TB!is!Not!top!ddx;!Primary!TB!in!
Children!usually!No!Hemoptysis)!
Bizarre!Honking!Cough!which!↑!with!Attention! Psychogenic!Cough!
Dry!Repetitive,!Disappear!with!Sleep! Habit!Cough!
Triggers?! Exercise,!Cold!air,!Early!Morning! Asthma!
Feeding! Recurrent!Aspiration!
! ! (Major!Ddx!of!Chronic!Cough!in!Children:!
! ! ! ! Asthma!
! ! ! ! Inhaled!Foreign!body!
! ! ! ! RSV!infection,!Pertussis,!Mycoplasma,!TB!
! ! ! ! Suppurative!Lung!disease,!eg.!Cystic!Fibrosis)!
Specific!Cough:! ! Associated!with!S/S!of!underlying!Resp/Systemic!disease!
Abnormality! Examples!of!Etiology!
Wheeze! Intrathoracic!airway!lesion!(eg.!Asthma,!Foreign!body)!
Crackles! Parenchymal!disease!
Chest!Pain! Arrhythmia,!Asthma,!↑Resp!distress!(Parenchymal!disease)!
Chest!wall!deformity! Chronic!Airway/Parenchymal!disease!
Digital!Clubbing! Chronic!Suppurative!Lung!disease!
Daily!Moist/Productive!Cough! Suppurative!Lung!disease!
Failure!to!Thrive! Serious!Systemic!including!Pulmonary!illness!
Feeding!difficulties! Serious!Systemic!including!Pulmonary!illness,!Aspiration!
Hypoxia/Cyanosis! Airway/Parenchymal!disease,!Cardiac!disease!
Neurodevelopmental!abnormality! Aspiration!Lung!disease!
Recurrent!Pneumonia! Immunodeficiency,!Congenital!Lung!anomaly,!TracheoEsophageal!Fistula!
! Typical!Cough!Association:!
! ! ! ! Whooping!Cough:! ! Pertussis!(Whoop:!HighTpitch!sound!from!Inhalation!after!Cough)!
! ! ! ! Barking/Brassy!Cough:! Croup,!Tracheomalacia,!Habit!Cough!
! ! ! ! Paroxysmal!(±Whoop):! Pertussis!
! ! ! ! Nocturnal:!! ! ! Upper/Lower!Resp!Allergy!(Postnasal!drip),!Sinusitis!
! ! ! ! Tight!(Wheezy):!! ! Reactive!airway!(1st!episode!is!Reactive!airway,!Recurrent!is!Asthma)!
! ! ! ! Staccato:! ! ! ! Chlamydia!
! ! ! ! Honking:! ! ! ! Psychogenic/Habit!
! ! ! ! (Specificity!&!Sensitivity!only!validated!in!Brassy!Cough!for!Tracheomalacia!(0.57,!0.81))!
Clue!from!Age!of!Onset!of!Cough:!

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Cough! in! Children!
! Aspiration! Airway! Bronchi! Infection! Sinusitis! Others!
Reactivity!
Infancy! ! Reactive! Congenital!Malformation:! Chlamydia,! ! Passive!Smoking,!
Airway! LaryngoTracheomalacia!or! Pertussis,!TB,! CHD!
Bronchomalacia,! PostTRSV!
Vascular!Compression!
(Ring/Sling!Innominate!artery)!
Childhood! ! !
Bronchiectasis:! Viral,! TB,!
Adolescent! (Degenerative! Smoking,!
Asthma! ID,!Cystic!Fibrosis,! Mycoplasma,! !
NM!disease)! Psychogenic,!
PostTInfectious! Fungal!
Mediastinal!Tumor!
NonSpecific!Cough:! Usually!PostTviral!Cough!or!another!episode!of!Acute!infection!
! ! ! ! ! Others:! Foreign!body,!Asthma,!Ear!problems,!GERD,!etc!
! ! ! ! Evaluate:! For!Tobacco!Smoke!&!other!Pollutants!
! ! ! ! ! ! Child’s!activity!
! ! ! ! ! ! Parental!Expectations!&!Concerns!
! ! ! ! Watch,!wait!&!review!
PE!in!Child!with!Chronic!Cough:!
! ! ! ! Growth!&!Development!
! ! ! ! Resp!distress!
! ! ! ! Digital!Clubbing!
! ! ! ! URT:!! Signs!of!Sinusitis:! ! Facial!Tenderness,!Persistent!Purulent!Nasal!discharge!
! ! ! ! ! ! Signs!of!Allergic!Rhinitis:! Nasal!obstruction,!Nasal!discharge!
! ! ! ! LRT:! ! Chest!deformity:! ! Harrison!sulcus,!Pectus!carinatum,!Barrel!chest!
! ! ! ! ! ! Hyperresonance!
! ! ! ! ! ! Crepitations,!Wheeze,!Rhonchi!
! ! ! ! Cardiac:! Murmur,!HF!
! ! ! ! Skin:!! Eczema!
Ix!according!to!Hx!&!PE:!
! ! ! ! CXR!
! ! ! ! Peak!flow!±!Lung!function!study!
! ! ! ! CBC!with!DC!
! ! ! ! Mantoux!test!(MT5)!or!Purified!Protein!Derivative!Test!(PPD)!for!TB!
! ! ! ! HRCT/MRI!
! ! ! ! Cilia!study!
! ! ! ! Ig!pattern!
! ! ! ! pH!probe!
! ! ! ! Video!Fluoroscopy!
! ! ! ! Bronchoscopy!
! ! ! ! Sputum/Gastric!aspirate!for!TB! (Children!swallow!Sputum>!Morning!Gastric!Aspirate!helpful)!
! Mantoux!Test:! Use!a!1mL!syringe!to!aspirate!out!0.1mL!of!PPD!RT!23!
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! ! ! ! Inject!PPD!intradermally!on!Volar!surface!of!Forearm!
! ! ! ! ! Position!syringe!at!10T15°!to!Forearm!&!Insert!just!below!Epidermis!(~2mm)!
! ! ! ! Remove!Needle!quickly;!Do!Not!massage!or!use!dressing!
! ! ! ! ! A!wellTdefined!Bleb!of!6T10mm!in!diameter!should!be!formed!if!injected!correctly!
! ! ! ! ! If!Bleb!<6mm,!Repeat!process!2.5cm!from!first!site!
! ! ! ! Mark!down!Site,!Date,!Time!of!Injection,!both!on!Forearm!&!Pt!record!
! ! ! ! After!48T72h,!read!result!by!marking!down!Transverse!diameter!of!Induration,!Not!Erythema,!
! ! ! ! ! by!Sokal’s!ballpoint!method!
! ! ! ! Measure!Largest!Transverse!diameter!of!Induration!&!Note!down!in!mm!
! ! ! ! ! Do!Not!write!test!result!+ve/–ve!
! Early!Morning!Gastric!Aspirate:!
! ! ! ! 3!consecutive!Early!morning!gastric!aspirate!for!AFB!smear!&!TB!culture!
! ! ! ! ! Comparable!Sensitivity!to!BAL!in!detecting!TB!if!well!performed!
! ! ! ! For!Young!child!who!is!unlikely!to!be!able!to!cough!up!sputum!
! ! ! ! By!waking!the!child!very!early!in!the!morning!before!he!walks!around,!eats!or!defecates!
! ! ! ! ! ie.!Before!major!peristalsis!drains!gastric!content!consisting!of!swallowed!sputum!
Tx:! ! ! ! Cough!is!a!Sx!telling!you!something!is!Wrong!
! ! ! ! ! Find!the!cause!
! ! ! ! Treat!the!underlying!cause!if!indicated!
! ! ! ! ! Very!diverse!Tx:!BD,!Surgery,!Antibiotics,!AntiTTB,!AntiTFungal,!Stop!Smoking,!etc!
! Antiviral:! ! No!specific!Antiviral!drug!available!in!most!Viral!infection:! ‘Bronchitis’,!Pneumonia!
! ! ! ! Available!for!Influenza:!
! ! ! ! ! Amantadine,!Oseltamivir,!Zanamivir!
! ! ! ! ! Not!to!treat!Cough!per!se!(Neuraminidase!inhibitors!shown!to!shorten!Fever!by!1.5!days)!
! ! ! ! ! Problem!with!↑ing!Resistance!(So!Amantadine!almost!Not!used!anymore)!
! ! ! ! ! (Zanamivir!is!by!Inhalation;!So!usually!for!Children!<7!yo!will!use!Oral!Oseltamivir)!
! Antibiotics:! CAP:!S.!pneumoniae,!H.!influenzae,!Moraxella!catarrhalis,!Mycoplasma!pneumoniae!
! ! ! ! ! Eg.!Augmentin,!Cefuroxime,!Clarithromycin!(Mycoplasma)!
! ! ! ! Pneumonia!in!Children!with!underlying!disease!
! ! ! ! ! Eg.!Pseudomonas,!S.!aureus!
! Cough!Suppressants:!
! ! Should!be!used?:!
! ! ! ! Natural,!Protective,!Beneficial!Mechanism!
! ! ! ! Critical!review!of!clinical!trials!1950T1991!(JAMA!1993)!
! ! ! ! ! Many!Antitussive!studies!performed!with!Artificial!Cough!
! ! ! ! ! ! (by!Citric!acid!or!Ammonia!inhalation!or!Chronic!Resp!disease)!
! ! ! ! ! No!good!evidence!of!effectiveness!of!OTC!Cold!medication!in!Preschool!Children!
! ! ! ! ! (Certain!Antitussive!may!work!for!Adolescents!&!Adults)!
! ! ! ! Cochrane!2004!(7!pediatric!studies,!516!children)!
! ! ! ! ! Studies!in!Children!with!Acute!Cough!
! ! ! ! ! ! Antitussive!No!more!effective!than!Placebo!

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! ! ! ! ! ! No!study!on!Expectorants!met!inclusion!criteria!
! ! ! ! ! ! 1!trial!favoured!Mucolytic!(Letosteine)!over!Placebo!from!d4Td10!
! ! ! ! ! ! 2!studies!–!No!difference!.//.!AntiHistamineTDecongestant!combinations!&!Placebo!
! ! ! ! ! ! 1!trial!showed!AntiHistamine!was!No!more!effective!than!Placebo!
! ! ! ! ! Conclusion:! No!good!evidence!for/against!effectiveness!of!OTC!drugs!in!Acute!Cough!
! ! Examples!of!Common!Ingredients!in!Cough!&!Cold!Medications:!
! ! ! ! AntiHistamine:! ! Diphenhydramine,!Cyproheptadine,!Brompheniramine,!Chlorpheniramine!
! ! ! ! Antipyretic!&!Analgesic:!
! ! ! ! ! ! ! ! Paracetamol,!Ibuprofen!
! ! ! ! Antitussive:! ! Codeine,!Dextromethorphan,!Hydrocodone!
! ! ! ! Expectorant:! ! Guaifenesin!
! ! ! ! Nasal!Decongestant:! Ephedrine,!Phenylephrine,!Pseudoephedrine,!Phenylpropanolamine!
! ! Are!they!Benign?!
! ! ! ! Codeine!&!Dextromethorphan!are!2!Antitussive!agents!frequently!used!in!Pediatrics!
! ! ! ! ! Work!by!acting!Centrally!suppressing!Medullary!Cough!centre!
! ! ! Codeine:! (Usually!Not!used!in!Children)!
! ! ! ! Narcotic!with!Addictive!potential!
! ! ! ! DoseTrelated!Toxicity:! ! Resp!Depression!&!Narcosis!
! ! ! ! Somnolence,!Ataxia,!Miosis,!Vomiting,!Rash,!Swelling,!Itching!
! ! ! Dextromethorphan:!
! ! ! ! Considered!Nonaddictive!but!Abused!by!Teenagers!
! ! ! ! ! Ingesting!Huge!doses!result!in!Bizarre!behaviour!
! ! ! ! CNS!depression!
! ! ! Combination!commonly!used:!
! ! ! ! Nasal!Decongestants,!AntiHistamine,!Cough!suppressants,!Expectorants!
! ! ! ! No!FDA!approved!dosing!exist!for!Children!<2!yo!
! ! ! ! M&M!reported!over!and!over!again!worldwide!including!HK!
! ! Recommendations!from!USA:!
! ! ! ! 1997!American!Academy!of!Pediatrics:!
! ! ! ! ! No!well!controlled!scientific!studies!to!support!efficacy!
! ! ! ! ! ! of!CodeineTcontaining!&!DextromethorphanTcontaining!Antitussives!in!Children!
! ! ! ! ! ! Indications!have!Not!been!established!
! ! ! ! ! Suppression!of!Cough!in!many!Pulmonary!diseases!may!be!Hazardous!&!Contraindicated!
! ! ! ! ! ! Cough!due!to!Acute!Viral!infection!is!ShortTlived!
! ! ! ! ! ! ! and!can!be!treated!with!Fluid!&!Humidity!
! ! ! ! ! Dosages!for!Children!are!Extrapolated!from!Adult!data!
! ! ! ! ! ! S/E!&!Overdosage!in!Children!are!reported!
! ! ! ! ! Education!of!Parents!about!Lack!of!proven!effects!&!potential!risks!is!needed!
! ! ! ! 2006!American!College!of!Chest!Physicians:!
! ! ! ! ! Refrain!from!recommending!Cough!Suppressant/other!OTC!Cough!Drugs!for!Young!Child!
! ! ! ! 11!Oct!2007:!

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! ! ! ! ! Manufacturers!Voluntarily!Withdrew!OTC!Cough!Cold!medicines!for!Kids!<2!yo!from!US!
Responsibility!of!Doctor:!
! ! ! ! Pediatrician!is!Child’s!advocate!
! ! ! ! ! We!treat!the!child,!Not!the!parents!
! ! ! ! ! Have!to!work!with!the!caretakers!
! ! ! ! Our!role!to!Educate!
! ! ! ! ! Natural!course!of!illness!
! ! ! ! ! Preventive!measures!when!applicable!
! ! ! ! ! Symptomatic!relief!is!Not!everything!
! ! ! ! ! Appropriate!therapy!include!Avoiding!inappropriate!therapy!
! ! ! ! Pt!are!Not!(only)!customers!
Summary:!! ! Cough!Tx!should!be!based!on!Etiology!
! ! ! ! No!evidence!to!support!medicine!for!Symptomatic!relief!
! ! ! ! Importance!of!Education!
!

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