Coughing is a protective mechanism that removes any inhaled irritants or mucus from the airways and lungs. However, chronic cough in children may indicate a problem. A chronic cough usually lasts for more than four weeks, while an acute cough lasts for less than two weeks. The condition may become bothersome to the child and the parent.
Coughing is a common pediatric complaint, and it may occur due to an underlying infectious or non-infectious factor. Chronic cough may require medical evaluation and treatment for timely treatment and prevention of any potential complications (1) (2).
Read on to know more about the causes, diagnosis, and treatment of chronic cough in children.
Causes Of Chronic Cough In Children
When there’s an irritant in the airway—nose, nasal passages, pharynx, larynx, trachea, or lungs—the airway nerves sensitize and send signals to the brain to remove the irritant. Coughing is a natural reflex that the brain triggers to push the irritant out.
Generally, a common cold or viral respiratory tract infection could cause an acute cough that lasts for a month or so. However, if the cough persists, it could indicate an underlying concern. Here’s a brief overview of the possible causes of chronic cough (3).
- Protracted bacterial bronchitis (PBB): Also known as chronic bronchitis of childhood, PBB is a prolonged and persistent bacterial infection of the airways (bronchi) that causes excessive mucus production and chronic wet cough (with phlegm). Since wheezing and cough are the main features of PBB, it is often misdiagnosed as asthma (4).
- Allergic rhinitis and sinusitis: When a child inhales something they are allergic to, such as pollen or dust, they may develop allergic rhinitis, a condition characterized by frequent sneezing, clear nasal secretions, and itchy, watery eyes. On the other hand, sinusitis causes a child’s sinuses to become blocked with thick, yellow-green mucus/fluid from inflamed nasal passages. In both cases, it is the allergin which causes the cough.
Both these conditions often lead to mucus/nasal secretions dripping into the back of the throat (post-nasal drip), causing a chronic cough. This usually occurs when the child lies flat and changes positions.
Note: A cough can be dry or wet depending on the cause. For instance, a dry cough is often linked to an allergy or asthma and due to bronchospasm. On the other hand, a wet or productive cough (with phlegm) can sometimes develop due to bacterial infection such as pertussis, mycoplasma, or pneumonia.
- Asthma: If a child wheezes, breathes with a whistling or rattling sound, or coughs even after falling asleep, it could be asthma. In asthma, the body’s cortisol levels dip during the night, triggering asthmatic bronchospasm. Bronchospasm causes the bronchial tubes (airways) to become narrow and inflamed, resulting in a chronic cough. Chronic cough is a common feature of asthma that, sometimes, can be the standalone symptom a child exhibits. The night cough can lead to disturbed sleep.
- Whooping cough (pertussis): Whooping cough is a vaccine-preventable bacterial infection that causes a cough so severe that the sufferer has to catch their breath by inhaling deeply, causing them to make a whooping sound. Generally, the cough due to pertussis is short-lived. However, in rare cases it may persist for months. The cough could last for months and lead to life-threatening complications such as pneumonia, low oxygen levels, apnea (breathing cessation), and seizures.
- Cystic fibrosis (CF): It’s a rare genetic disorder in which the glands produce thick, sticky mucus that can accumulate and cause blockages in different organs, damaging them progressively (5). It is caused by faulty body proteins that affect the cells, tissues, and glands. When CF affects the lungs, it causes chronic lung infection with a persistent cough, recurrent respiratory infections, inflammation of the bronchioles (bronchiolitis), and recurrent or chronic irritation and inflammation of the sinus lining (rhinosinusitis). Cystic fibrosis has other features too.
- Gastroesophageal Reflux Disease (GERD): It is a gastrointestinal problem commonly associated with heartburn, abdominal cramps, and nausea or vomiting but not chronic cough. However, if a child has an underlying respiratory problem, acid reflux can worsen it and aggravate the cough. Reflux-related coughing is usually dry and is more frequent during the day when the child is upright.
Also, it aggravates after meals and while laughing, talking, and singing excessively. Citrus fruits and juices, high-fat food, pickled vegetables, and caffeinated or carbonated beverages can worsen reflux-related cough.
- Aspiration: It occurs when food or liquid enters the lungs through the trachea (6) Chronic cough is one of the most common symptoms of aspiration. This chiefly occurs when the swallowing mechanism is disturbed. Recurrent pneumonia and neurological conditions, such as vocal cord paralysis, are some of its possible causes.
- Airway blockage: A foreign object stuck in their airway can also cause chronic cough. This is a very common cause of chronic cough. The foreign body inhalation may go unnoticed and not accompanied by choking. Seek immediate medical assistance if your child develops a chronic cough after a choking event. Generally, after a choking event, a child can stay asymptomatic for up to two weeks before developing complications, such as pneumonia.
- Habit cough (psychogenic cough or somatic cough syndrome): It often develops after a child has been coughing due to a respiratory infection and persists even after the issue has been resolved. However, the child may not cough when preoccupied or asleep (7). In most cases, a psychogenic cough worsens if the child is anxious or stressed. As a habit cough sounds like a loud bark or honking, it is also known as barking or honking cough.
Besides these, passive smoking, tuberculosis, and congenital abnormalities of the gastrointestinal tract and airway, such as chronic obstructive pulmonary disease (COPD), can cause breathing problems, resulting in chronic coughing (8).
Diagnosis Of Chronic Cough In Children
The diagnosis of chronic cough begins with a physical examination where the doctor observes the child’s respiratory patterns and listens for unusual breathing sounds, such as wheezing or crackling. Then, they collect the child’s medical history and ask questions, such as (8)
- When did the cough start?
- Is the cough productive or dry?
- Is the cough more in the day or at night?
- What are the other symptoms the child is experiencing?
- Has the child contracted any illness, such as a viral infection, in the past?
- Does the child possess any risk factors in terms of abnormal airway passages and chronic diseases?
Based on the suggestive findings, the doctor may order some of the following tests to confirm the diagnosis.
- Lung function tests: These tests can help locate the exact cause of chronic cough and are performed in children aged five years and above.
- Spirometry: It’s the most common breathing test performed to measure lung function and check for signs of asthma (9). For a spirometry test, the child is asked to blow into a spirometer, which measures how much and how quickly and easily the child can blow out air.
- Bronchodilator challenge test: In this test, the child has to blow into a spirometer before and after taking a medicine that opens their airways. It helps confirm that the child has chronic cough due to asthma.
- Impulse oscillometry (IO): It is a non-invasive test that measures lung mechanics using sound waves. In the test, the child breathes normally into a tube that measures pressure changes and flows to calculate pulmonary resistance. It is useful for testing the lung function of children under five years of age.
- Exercise challenge: This test involves a child breathing into a spirometer before and after riding a stationary bicycle. The test measures the child’s lung function and may help determine if cough is caused by exercise-induced asthma.
- Bronchoscopy: It’s an invasive test performed under anesthesia. A pulmonologist inserts a camera-donned flexible tube (bronchoscope) into the child’s nose or mouth and moves it through their airways to observe and locate any blockages or tissue damage, such as scarring. The test is advised for children when the cause of chronic cough can’t be determined with a physical exam and sputum culture or the cough persists even after treatment. It is extremely helpful in diagnosing cases of foriegn body inhalation.
- Sputum culture: A sputum culture helps determine if a bacterial infection is causing the chronic cough. For the test, a pathologist takes a sample of the child’s mucus and examines it for bacterial presence. If the test is positive, the pathologist will investigate further to identify the bacteria type and prescribe the right antibiotic treatment.
- Chest X-ray: It allows the doctor to observe the anatomy of the lungs and locate abnormalities if present. It is a helpful tool for ruling out unusual causes of chronic cough that other exams may fail to detect. It can help in coming to a conclusion about the cause of the cough.
The test the doctor opts for depends on the suspected cause of the chronic cough. For instance, if chronic cough is suspected to be caused by aspiration, a speech-language pathologist will perform a videofluoroscopic swallow study (VFSS) or a flexible endoscopic evaluation of swallowing (FEES) to determine or confirm the cause. After determining the cause, they may refer you to a specialist, such as a pulmonologist, allergist, or otolaryngologist (ENT).
There are some other supporting tests, including blood CBC (complete blood picture), ESR, Tuberculin test that help in the diagnosis.
Treatment For Chronic Cough In Children
The treatment for chronic cough depends on its cause. For instance, viral respiratory infections that cause daytime coughs are usually self-limiting and do not require specific treatment. On the other hand, if a child has chronic cough due to habit cough, the child’s abnormal reflex can be improved using speech and behavioral therapy. Also, the child can sip water or drink warm liquids to suppress their urge to cough.
The following are different medications a doctor may use to treat chronic cough. The medication the doctor prescribes depends on the child’s age, the cause of the cough, the severity of the cough, and overall health (10)
- Antibiotics: Antibiotics treat bacterial infections and resolve the symptoms within ten to 14 days. Generally, oral antibiotics should be adequate for chronic cough. Depending on the infection’s severity, they can be administered orally or via an intravenous infusion (IV). The antibiotic your child needs depends on the bacteria causing the infection. For instance, a healthcare provider may prescribe broad-spectrum antibiotics for two weeks or longer to eliminate different bacteria types from their airways.
- Anti-inflammatory medications: These medications alleviate inflammation in the airways. They are often prescribed to children with cough-variant asthma, a breathing disorder wherein the child has no symptoms other than persistent cough.
- OTC antihistamines and steroids: Antihistamines and nasal steroids can help relieve inflammation and alleviate coughs caused by an allergy.
Note: Do not give over-the-counter decongestants or cough suppressants, such as those containing dextromethorphan and codeine, to children. These are now specifically contraindicated. These medications can lead to side effects in young children.
- Saline nasal spray or a suction syringe: These can be used to clear nasal congestion and reduce the severity of coughing.
Most children experience relief from chronic cough with timely diagnosis and proper treatment. However, if the cough continues, the doctor would do a more thorough analysis and choose a treatment course accordingly.
Home Remedies For Chronic Cough
Besides the suggested treatment, you could follow some home remedies for effective management of cough in children (11).
- Give your child plenty of fluids such as water, soup, and decaffeinated tea. Avoid offering carbonated drinks or citrus juices, as they can irritate the throat. This home remedy is effective for relieving cough caused by the common cold.
- Run a cool-mist humidifier or vaporizer in your child’s room at night. It will help relieve nasal congestion, open the airways, and alleviate cough.
- Feed your child half to one teaspoon of honey in decaffeinated tea or toast to loosen the mucus. This remedy is safe for children aged above one year.
- Apply a warm compress to ease headaches and facial pains that the child may have due to persistent coughing.
- Make your home allergy-proof to ensure your child doesn’t develop chronic cough due to allergy. This can be done by:
- Avoiding dusty environment
- Keeping your house clean.
- Washing bed linens, curtains, etc., weekly.
- Cleaning stuffed toys often.
- Keep your child away from second-hand smoke, especially if they have any underlying respiratory problems, such as asthma.
- Steam inhalation or nebulization with normal saline.
Here are some more home remedies for cough that you can try after consulting your pediatrician. Usually, prompt treatment and home care help resolve chronic cough. However, if the cough persists, causes loss of appetite, brings up sputum or blood, or affects the child’s health in any way, seek medical assistance immediately.
Since several underlying issues could cause a child to develop chronic cough, it is essential that an expert examines the child and determines the precise cause to help chart out the most suitable treatment plan that could offer relief to the child.
- Protracted bacterial bronchitis, allergic rhinitis, sinusitis, whooping cough, and asthma are common causes of chronic cough in children.
- Along with physical examination, lung function tests, such as spirometry, sputum culture, and x-ray, are diagnostic tests a doctor may use to determine the cause.
- Prompt treatment based on the child’s age and the cause and severity of the cough can offer relief to most children.
- Keeping your child hydrated, applying warm compresses, and running a cool-mist humidifier or vaporizer are some of the home remedies you could follow.
- Why Does My Child Have a Chronic Cough
- Robert Kaslovsky and Matthew Sadof; (2013); Chronic Cough in Children: A Primary Care and Subspecialty Collaborative Approach
- Chronic Cough in Kids
- Protracted Bacterial Bronchitis (PBB) in Children
- Cystic Fibrosis
- Psychogenic Cough (Somatic Cough Syndrome)
- Diagnosing Chronic Cough
- What Is Spirometry and Why It Is Done
- Medications for Chronic Cough
- Coughs: Meds or Home Remedies