Childhood cough

1 . R ega rdin g den it ion s of c ou gh in c h ildh ood, wh ic h of t h e followin g is c orrec t ?

Y o u r an s we r a. b. c. d. Co r r e ct an s we r

Chronic cough is dened as cough that persists for more than a week Chronic cough is dened as cough that persists for three to 12 weeks Acute cough is dened as cough that resolves within two weeks Acute cough is dened as cough that resolves spontaneously no matter what its duration

a : Ch ron ic c ou gh is den ed a s c ou gh t h a t persist s for m ore t h a n a week Acute cough is typically dened as being of less than three weeks duration and chronic cough is variably dened as lasting from three to 12 weeks. British Thoracic Society guidelines dene chronic cough as cough that lasts longer than eight weeks, with the stated caveat of a grey area of prolonged acute cough or subacute cough in children with pertussis or postviral cough that takes three to eight weeks to resolve. b : Ch ron ic c ou gh is den ed a s c ou gh t h a t persist s for t h ree t o 1 2 week s Acute cough is typically dened as being of less than three weeks duration and chronic cough is variably dened as lasting from three to 12 weeks. British Thoracic Society guidelines dene chronic cough as cough that lasts longer than eight weeks, with the stated caveat of a grey area of prolonged acute cough or subacute cough in children with pertussis or postviral cough that takes three to eight weeks to resolve. c : Ac u t e c ou gh is den ed a s c ou gh t h a t resolves wit h in t wo week s Acute cough is typically dened as being of less than three weeks duration and chronic cough is variably dened as lasting from three to 12 weeks. d : Ac u t e c ou gh is den ed a s c ou gh t h a t resolves spon t a n eou sly n o m a t t er wh a t it s du ra t ion

Acute cough is typically dened as being of less than three weeks duration and chronic cough is variably dened as lasting from three to 12 weeks. Most children with acute cough have a viral infection of the upper respiratory tract, which is self limiting.

2 . W h ic h of t h e followin g st a t em en t s a bou t t h e c h ild wit h a c u t e c ou gh is m ost a c c u ra t e?

Y o u r an s we r a. b. c. d. Co r r e ct an s we r

Acute cough that is caused by a viral infection will never need further investigation Acute cough is seldom the presenting feature in a child who has inhaled a foreign body In child with an acute cough who is not tachypnoeic a pneumonia can be safely ruled out It is unwise to take parental anxiety into account when assessing a child with an acute cough because this will lead to over-investigation and overtreatment

a : Ac u t e c ou gh t h a t is c a u sed by a vira l in fec t ion will n ever n eed fu rt h er in vest iga t ion Most acute coughs are caused by infection of the upper respiratory tract that will need no specic clinical investigations. However, viral infection of the lower respiratory tract may also present with cough and, owing to the more serious clinical syndrome, this may require investigation. b : Ac u t e c ou gh is seldom t h e presen t in g fea t u re in a c h ild wh o h a s in h a led a foreign body Acute cough may be the presenting feature in a child who has inhaled a foreign body. c : In c h ild wit h a n a c u t e c ou gh wh o is n ot t a c h ypn oeic a pn eu m on ia c a n be sa fely ru led ou t Systematic reviews have shown that the best single nding to rule out pneumonia is the absence of tachypnoea. d : It is u n wise t o t a k e pa ren t a l a n x iet y in t o a c c ou n t wh en a ssessin g a c h ild wit h a n a c u t e c ou gh bec a u se t h is will lea d t o over-in vest iga t ion a n d overt rea t m en t Parental concern remains an important red ag for serious illness in settings with a low prevalence of serious infection.

3 . W h ic h of t h e followin g st a t em en t s a bou t t h e c h ild wit h c h ron ic c ou gh is m ost a c c u ra t e?

Y o u r an s we r a. b.

Co r r e ct an s we r

Pertussis may be a common cause of chronic cough Cough that has been recurrent and persistent since early infancy is likely to be psychogenic and does not warrant referral to a specialist In countries where newborn screening for cystic brosis is routine, a child with chronic cough is exceedingly unlikely to have a new diagnosis of cystic brosis Persistent bacterial bronchitis is a condition that is found in adult smokers and is not part of the differential diagnosis for chronic cough in children

c.

d.

a : P ert u ssis m a y be a c om m on c a u se of c h ron ic c ou gh A prospective cohort study of school aged children presenting to primary care with a cough lasting 14 days or more found that around a third had serological evidence of recent Bordetella pertussis infection, and nearly 90% of those children had been fully immunised against pertussis. b : Cou gh t h a t h a s been rec u rren t a n d persist en t sin c e ea rly in fa n c y is lik ely t o be psyc h ogen ic a n d does n ot wa rra n t referra l t o a spec ia list Chronic cough that has been recurring since early infancy, particularly since the neonatal period, is a red ag that should prompt swift referral for specialist assessment. c : In c ou n t ries wh ere n ewborn sc reen in g for c yst ic brosis is rou t in e, a c h ild wit h c h ron ic c ou gh is ex c eedin gly u n lik ely t o h a ve a n ew dia gn osis of c yst ic brosis Newborn screening can miss cases of cystic brosis and some children will still present clinically with chronic respiratory symptoms, malabsorption, or growth faltering. d : P ersist en t ba c t eria l bron c h it is is a c on dit ion t h a t is fou n d in a du lt sm ok ers a n d is n ot pa rt of t h e differen t ia l dia gn osis for c h ron ic c ou gh in c h ildren Persistent bacterial bronchitis in children is increasingly recognised in children who have a chronic wet cough, but the diagnosis is often one of exclusion.

4 . W h ic h of t h e followin g st a t em en t s a bou t t h e a ssoc ia t ion bet ween a st h m a a n d c ou gh is c orrec t ?

Y o u r an s we r a. b. c.

Co r r e ct an s we r

Nocturnal cough without wheeze is common in children with asthma A child with a chronic nocturnal cough without any wheeze is unlikely to have asthma In a child under the age of 2 years who has a chronic cough and no features suggestive of infection, asthma is the most likely diagnosis

a : Noc t u rn a l c ou gh wit h ou t wh eeze is c om m on in c h ildren wit h a st h m a Evidence from prospective observational studies suggests that in the absence of wheeze or dyspnoea very few children with non-specic isolated cough have asthma. Only a small proportion of children with non-specic isolated cough have eosinophilic airway inammation. b : A c h ild wit h a c h ron ic n oc t u rn a l c ou gh wit h ou t a n y wh eeze is u n lik ely t o h a ve a st h m a Evidence from prospective observational studies suggests that in the absence of wheeze or dyspnoea very few children with non-specic isolated cough have asthma. Only a small proportion of children with non-specic isolated cough have eosinophilic airway inammation. c : In a c h ild u n der t h e a ge of 2 yea rs wh o h a s a c h ron ic c ou gh a n d n o fea t u res su ggest ive of in fec t ion , a st h m a is t h e m ost lik ely dia gn osis Asthma is unusual in children under 2 years of age.

5 . R ega rdin g t h e m a n a gem en t of t h e c h ild wit h c h ron ic c ou gh , wh ic h of t h e followin g st a t em en t s is c orrec t ?

Y o u r an s we r a. Co r r e ct an s we r

In an otherwise well child in whom no underlying cause can be found for a chronic cough parents can be reassured that no further management is necessary There is no evidence that exposure to aeroirritants such as tobacco smoke plays any role in the cause or resolution of chronic cough Never use a trial of anti-asthma drugs in a child with a chronic cough who does not wheeze A trial of anti-asthma drugs in a child with a chronic cough who does not wheeze may be

b.

c. d.

considered when there is a strong family history of asthma a : In a n ot h erwise well c h ild in wh om n o u n derlyin g c a u se c a n be fou n d for a c h ron ic c ou gh pa ren t s c a n be rea ssu red t h a t n o fu rt h er m a n a gem en t is n ec essa ry There is a place for watchful waiting, but this should be limited to six to eight weeks and followed by a thorough review to check that the cough has resolved and no specic features have developed. b : Th ere is n o eviden c e t h a t ex posu re t o a eroirrit a n t s su c h a s t oba c c o sm ok e pla ys a n y role in t h e c a u se or resolu t ion of c h ron ic c ou gh Although there is limited evidence that removal of aeroirritants is helpful, there is considerable evidence that environmental exposure is associated with increased coughing, so it is sensible to remove such exposure. c : Never u se a t ria l of a n t i-a st h m a dru gs in a c h ild wit h a c h ron ic c ou gh wh o does n ot wh eeze There is a place for considering a trial of an inhaled corticosteroid as anti-asthma treatment in a child with features of atopy or a strong family history of asthma. The trial treatment should be effectively delivered in adequate doses, with clearly dened outcomes recorded over a set periodfor example, eight to 12 weeksfollowed by cessation of treatment to complete evaluation of the response to treatment. d : A t ria l of a n t i-a st h m a dru gs in a c h ild wit h a c h ron ic c ou gh wh o does n ot wh eeze m a y be c on sidered wh en t h ere is a st ron g fa m ily h ist ory of a st h m a There is a place for considering a trial of an inhaled corticosteroid as anti-asthma treatment in a child with features of atopy or a strong family history of asthma. The trial treatment should be effectively delivered in adequate doses with clearly dened outcomes recorded over a set periodfor example, eight to 12 weeksfollowed by cessation of treatment to complete evaluation of the response to treatment.

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