Management of Cough

in Children

Nastiti Kaswandani

Child Health Dept FKUI/RSCM

Respirology WG – Indonesian Pediatrics Society
 Introduction

• Cough is one of main symptoms in children

• It can be normal, but prolonged and chronic
cough can disturb child’s activities and
growth/development
• The wide range of etiology cough in children
• Many drugs have been used for cough, even
the evidence of their efficacy is unclear
 Definition & Mechanism
Cough : a sudden explosive expiratory maneuver
that tends to clear materials from the airways
and prevent aspiration of food or fluid

McCool FD.Chest
2006;129:48s-53s.
Cough reflex arc

Chang AB. Cough 2005;7:1-15.

 C o u g h
Friend OR
• A part of respiratory
defense mechanism
• Useful to clear up the
airway (mucocilliary
clearance) from
– inhaled materials
– abnormal fluid accumulation
(pus)
• To preventforeign body
aspiration into the lung
• It can be an alarm of
pathologic conditions
Foe ??
• Disturb activities
– Cause fatigue
– Sleepless
– Musculoskeletal aching
– Hoarseness
– Urinary incontinence
• Cough : effective mode of
airborne disease
transmission
 Classification of Cough
• Based on duration of symptoms
– acute cough (< 3 weeks)
– prolonged acute cough (3-8 weeks)
– chronic cough (> 8 weeks).

IPS(IDAI): Batuk Kronik Berulang (BKB)

 chronic: > 2 weeks AND/OR
 recurrent: > 3 episodes in 3 months
• Based on characteristic of cough
– Dry vs wet (productive cough)
– Whooping, spastic, barking, stacato, honking cough
 Acute and Prolonged Cough
 Normal children have up to 34 cough per 24 hour
 Acute cough mostly caused by acute upper respiratory
infection
 ARI can happen 5-8 times per year, 75% resolve in 1 week,
94% in 2 weeks
 No tachypnoea and chest indrawing  not need any
investigations.

PROLONGED / SUB ACUTE

 Consider pertussis or postviral cough whose cough may be
slowly resolving over a 3–8-week period

Shields MD. Thorax 2008;63:1-15.

 Clinical Approach
Chronic Cough in Children
Important Points in Diagnostics
 Knowledge of cough mechanism and location of cough
receptor

 A child is not a small adult; difference in :

 growth and development
 disease pattern and symptoms
 Etiology

 Age difference

 Cough could be :
 a protective mechanism
 warning sign of disease
 detrimental symptoms when persist and excessive
 Anamnesis
Time Age onset Since birth Premature

Infancy Mature

Children

Adolescent

Duration Weeks

Month - years

Occasional

Time occurrence Night and day

Never at sleep
Etiology Chronic Cough in Children

Infancy Early Childhood Late childhood

Gastro Esophageal Post-viral airway Asthma
Reflux (GER) Hyper-
responsiveness
Infection Asthma Post Nasal Drip
Congenital Passive smoking Smoking
Malformation
Congenital Heart GER Pulmonary
Disease Tuberculosis
Passive Smoking Foreign body Bronchiectasis
Environmental Bronchiectasis Psychogenic
Pollution cough
Chow PY. Singapore Med J. 2004;45:462-9.
Asthma
Specific cough pointers
Presence of :
 Haemoptysis
 Recurrent pneumonia
 Exertional dyspnea
 Chronic sputum production
 Wheeze
 Stridor
 Immune deficiency
 Cardiac abnormality
 Swallowing difficulties
 Dyspnea
 Chest deformity
 Clubbing
 Ausculatory abnormality
 Poor growth

Note : In non specific cough these pointers are absent. The etiology is in
majority related to post viral cough and/or increased cough receptor
sensitivity

Chang AB, Cough, 2003

 Physical Examination
Characteristic Productive Yes Moist
of cough No Dry

Specific sound Bark or brassy

Honk

Paroxysmal
Specific circumstances
Whoop
Activity
Wheeze
Certain position
Snoring
Certain condition or place
Hoarse

Stridor
 management

10
 Cough Management
• Pharmacologyc
• Non Pharmacologyc
 Environment Control
(indoor and outdoor)
 Avoidance
 Plenty of water
for hydration
 Drugs for Cough
• Depend on the etiology
• Main drugs
– Bronchodilator  bronchoconstriction
– Antibiotic: etiology  bacterial infection
– Anti-inflammation  airway inflammation
• Supporting drugs
– Mucoactive (protussive agent)
– Antitusive ?
 Pharmacologic Therapy
(based on etiology of cough)
Disease Drugs Examples
Asthma Bronchodilator Salbutamol, procaterol,
Fenoterol, terbutaline

Inhaled Steroid Budesonide, fluticason

Rhinosinusitis / Nasal Steroid Mometasone, fluticason

Allergic rhinitis
Anti histamine Cetirizine
Pertussis Antibiotics Azythromicin, clarythro
macrolide
Tuberculosis Anti TB RHZE
GERD PPI Omeprazole
 COUGH EFFECTIVENESS
DEPENDS ON
• The ability to generate high velocities of the air
stream
Dispersion of liquid mucus into the air stream
(misty flow)
Increase the waves of mucus
Vibration of the bronchus wall
• The physical property of the mucus

McCool FD. Chest 2006;129:48S-53S.

 IMPAIRED OF MUCOCILIARY
• Altered mucus rheology
- increase viscosity, decreased elasticity
- increase secretion

• Ciliary impairment
- primary dyskinesia (genetic defect)
- secondary dyskinesia (infection,
polutants)
 ENHANCED MUCOCILIARY
CLEARANCE
• Physioterapeutic regimen
(postural drainage, positive expiratory
pressure, forced expiration technique,
regular exercise)

• Pharmacological therapies
“mucoactive agent”
 Anticholinergic Opioids
Expectorant
Mucolytic

Anti-inflammatory:
Corticosteroids
Leukotriene antagonist

15 Bronchodilator

Cough reflex afferent pathway and drug center activity

 MUCOLYTIC
• Drugs that decrease mucus viscosity
Classic mucolytics
- N acetylcystein (NAC): may dissociate mucin disulphide
bonds and other disulphide bond cross-linked gel
components to reduce viscosity
- Erdostein : metabolite act as NAC

Peptide mucolytics
rhDNAse
Break down the highly polymerised DNA and F-actin network
eg. rhDNase proteolytic enzyme that cleaves DNA polymer

Non-destructive mucolytics
Dextran and Heparin
Dissociate or disrupt the polyionic oligosaccharide mucin
network by a mechanism termed “charge shielding”
 Acetylcysteine and carbocysteine for
acute upper and lower respiratory tract
infections in paediatric patients without
chronic broncho-pulmonary disease
(Review)

Six trials involving 497 participants

They showed benefit for mucolytics
(reduction of cough at day seven)
Overall safety was good , very few data were available
in infants younger than two years.
Mucolytics acetylcysteine and carbocysteine could be
used for acute URTI and LRTI in pediatric patients

Chalumeau M, 2013
 Erdosteine + Amoxicillin
80 Amoxicillin
67.08
63.27
60
Tingkat Keparahan

44.7
40 33.64

17.48
Batuk

20
6.54

0
base line hari ke-3 hari ke -7
Multicenter, RCT to compare a combination of erdosteine-amox VS
placebo-amox combination in children with ALRI

A total of 158 patients (78 erdosteine group and 80 placebo group) were
treated for 7 +/- 2 days

The severity of cough was decreased by 47% at Day 3 in the

erdosteine group with a statistically significant difference, & still
significant at the final visit.

The decrease in the severity of rales was significantly greater at Day 3

in the erdosteine group than in the placebo group

No important adverse reaction have been observed and also the

biological safety was ensured
To evaluate erdosteine as adjuvant therapy in rhinosinusitis
RCT, double blind

Complete improvement 78% in treatment, 74.4% in control

There were NO clinically detected serious side effect or
complications
Safety & tolerability
 Anti Tussive and OTC Drugs
• Children are different from adult.
• OTCs (antitussives, antihistamine, decongestant,
analgetics) has no benefit in the symptomatic
control of cough in children.
• OTCs have significant evidence in morbidity and
mortality.
• Only in certain condition anti-tussive can be
given to children with cough, for example for
pertussis.
Schaefer MK. Pediatrics 2008; 121: 783 - 787.
Rimsza ME. Pediatrics 2008; 122: e318 - e322.
Cough Remedies
 Conclusion
• Cough in children is caused by various etiology.
• Age of children and specific pointers of chronic
cough can guide to certain diagnosis
• The management of the cough is based on the
underlying diseases.
• Physicians should aware in prescribing cough
and cold medications which contains antitussive,
anti histamine or other symptomatic drugs
• Mucoactive agent can help to produce effective
cough for clearing the mucous
Thank you
 CXR
Spirometry (if >6 yrs)
Both normal Either abnormal Consider early consultation with pediatric
Pulmonologist for assessment
Reversible airway obstruction ?

Asthma yes no
Absence of “other features”, wheeze If cough does not
And productive/wet cough ? Settle consider
Assess risk factors for
yes no
Bronchiectasis Aspiration Chronic or Interstitial Cardiac
Non specific cough Or recurrent Less Lung
Other features • Pulmonary
Present ? pneumonia • Primary and Common disease Hypertension
Consider : Secondary
Neurologically
infections • Cardiac
• Post viral • Cystic fibrosis • Rheumatic Oedema
no yes Abnormal • TB
• increased CRS • Ciliary dyskinesia Diseases
• Altered swallow •
• Asthma • Previous severe Non Tuberculous• Cytotoxics
• Weak cough
pneumonia Mycobacteria Drugs
• GER Purulent productive or Reflex • mycoses • Radiation Pediatric
• Immunodeficiency
• UA problems Moist/wet cough and • Neuromuscular
• Structural airway • etc cardiologist
Disease
• Functional Without wheeze lesions • Laryngeal
disorders (habit • Congenital lung
Abnormalities
yes no lesions
cough, tics, • Missed foreign
• Tonsil adenoid
psychogenic) Hypertrophy Mantoux Autoimmune Echo
body • TEF/H-fistula Bronchoscopy Markers Cardiac
• TEF/H fistula
Sub-acute Asthma • Severe GER & lavage HRCT chest catheter
bronchitis HRCT chest Lung biopsy
But reviews
Needs follow-up; if for Other
Recurrent or causes of Sweat test Ba swallow
Persistent, needs wheezing Bronchoscopy Bronchoscopy & lavage
investigate
Cilia biopsy Video fluoroscopy
Immune workup pH monitor
HRCT chest Lung milk
Ba swallow Scan/salivagram
Review and if “other features” present

Pathway 3: Chronic or acute cough associated with other symptoms

 Guidelines
Wheezing, other atopy Asthma
Specific pointers
identified from Clearing throat, allergic salute Post nasal drip/allergic rhinitis Persistent endobronkial
Yes
anamnesis, physical infection:
Wet/productive cough •Cystic fibrosis
examination, chest x-ray
and spirometry •Primary ciliary dyskinesia
Choking with feeds,
(>6years) Reccurent aspiration •Persistent bacterial bronchitis
chesty after
feeds Tracheo/bronkomalaci, •Immune deficiency
Brassy or barking cough
No airways compression
Cough bizzare,
dissapear when asleep Psychogenic cough
Nonspecific cough Dry cough, breathless
otherwise well child Interstitial lung disease
restrictive spirometry

Progressive cough, weight loss, fevers TB

Is the cough truly
troublesome?

Stop anti- Restart anti-asthma

No Yes asthma medication only if
medication cough relapses
Response
Reassure, Trial anti-asthma
observe, medication Stop anti-
follow up Consider futher
No response asthma investigation and
medication follow up

Shields MD, Bush A, Everard ML. Recommendations for

the assessment and management of cough in children.
Thorax 2008;63:1-15.