Adam Jaffe at DFTB19
Adam is a respiratory physician at Sydney Children’s Hospital. He spoke about all things wheezy in Melbourne for DFTB18. In this talk from our London conference, he deals with that bane of parents’ lives – the coughing child. Let’s hope it’s not pertussis.
Diagnosing and managing persistent coughs, especially in pediatric patients, demands a thoughtful and comprehensive approach.
The Case of Alice: A Chronic Cough Mystery
Let’s start with a typical case.
Alice’s parents sought medical help because their daughter had been experiencing relentless coughing for years. Despite her uneventful birth and normal early life, her coughing episodes were causing significant distress. These episodes of paroxysmal, dry coughing spells often kept her awake at night, disrupted her parents’ sleep, exhausted her, and affected her performance at school. It was a classic case of chronic cough, and Dr. Jaffe embarked on a journey to uncover the underlying causes.
Cough as a Reflex
Coughing is a reflexive response triggered by many factors, including acid reflux, upper respiratory tract infections, inflammation, and mucus. Importantly, while coughing is a reflex, cough receptors play their part in controlling it. These receptors exist in different body parts, such as the large airways, heart, and stomach. Understanding this control mechanism is crucial when dealing with chronic coughs in children.
Is it a cough or asthma?
While there is a condition known as “cough variant asthma” or “cough-predominant asthma,” it is essential to recognize that coughing in this context fundamentally differs from cough caused by other factors. The triggers and mechanisms behind cough-variant asthma are distinct from those of other chronic coughs.
Investigating Chronic Cough
When faced with a child experiencing a chronic cough, start by taking a thorough history. This step is crucial in understanding the nature of the cough, its triggers, and any associated symptoms.
Ask about the onset, duration, and characteristics of the cough, as well as factors that exacerbate or alleviate it. This comprehensive history can guide further investigations and help identify potential underlying causes.
Determining Normal vs. Abnormal Cough
On average, a normal child may cough around 11 times a day. However, it’s essential to consider the duration of the cough. According to British Thoracic Society guidelines, a cough lasting longer than eight weeks is considered abnormal. On the other hand, Australian guidelines set the threshold at four weeks. Understanding these distinctions helps determine whether a child’s cough should be a cause for concern.
Chronic coughs can be classified based on their underlying causes. There are specific causes of cough, such as upper respiratory tract infections or cystic fibrosis, which are directly linked to the cough. However, there is also the category of nonspecific cough, which can be more challenging to diagnose. These nonspecific coughs are often labelled as “viral-induced cough” or “post-viral cough,” highlighting the complexity of categorizing cough in children.
Recognizing the Significance of Wet Cough
A wet cough lasting longer than eight weeks is a cause for concern. This type of cough may indicate a condition known as persistent bacterial bronchitis, often caused by pathogens like Haemophilus influenzae or Streptococcus pneumonia.
These bacteria form biofilms in the airways, triggering a chronic, productive cough. Timely recognition and appropriate treatment are crucial to prevent progression to more severe lung conditions.
Psychogenic Cough: A Complex Diagnosis
Psychogenic cough is a conversion disorder where psychological factors manifest as physical symptoms, in this case, a persistent cough. The hallmark of psychogenic cough is that it often worsens when the child is relaxed, such as when going to bed. Treating these patients can be a challenge and requires a multifaceted approach, including cognitive-behavioural interventions, hypnosis, and sometimes medications like gabapentin and amitriptyline.
Approaching the Conversation with Parents
One of the key challenges in managing chronic coughs in children, especially when a psychogenic cough is suspected, is communicating effectively with parents. These conversations can be delicate, and there is no one-size-fits-all approach. The approach to discussing the possibility of a psychogenic cough depends on the therapeutic relationship with the parents and their level of understanding. Be empathetic and provide resources and information to support parents in understanding the diagnosis and treatment options.
Chronic coughs in children present a complex clinical challenge, often requiring a multidimensional approach. Understanding the differentiation between normal and abnormal cough, recognizing the significance of wet cough, and effectively addressing psychogenic cough are essential aspects of managing chronic coughs in children. By incorporating these insights into their practice, medical professionals can better diagnose and treat this challenging condition, ultimately improving the quality of life for their young patients.