Childrens Medical Office - of North Andover, P.C.

Cough - General Considerations

Cough is another one of a child's most fundamental defense mechanisms. It is what keeps things in the upper respiratory tract from moving down into the lungs, and it is what rids the lungs of an illness already there. This function is vitally important, as the lungs bring life-sustaining oxygen into the bloodstream.

Because of the above, to "suppress" or interfere with one's ability to cough without effectively dealing with the cause of that cough makes no sense and is really playing with fire. Yet this is exactly what many medicines sold over-the-counter claim to do! If such medicines worked they would be dangerous - they would make you sleep better with your cold tonight but be more likely to wake up with pneumonia in the morning! Luckily, they tend to be ineffective and are thus, at best, a waste of money. "Cough medicines" are therefore NEVER recommended.

As with fever, you should view your child's cough as a warning, and be on the lookout for signs of serious illness or clues as to what exactly may be wrong. The main thing to watch for is true difficulty breathing or SHORTNESS OF BREATH. A child may have both a bad cough and very noisy breathing and still not be short of breath. Signs of true difficulty breathing should prompt you to call immediately regardless of what other symptoms may be present. They include:

blueness around the lips or fingernails

increased breathing rate
(>80x/minute in infants, >40 in older children)

caving or pulling in of the chest wall while inhaling
or "retracting" of skin between the ribs

a look of fear or anxiety in the child's eyes

in an infant, inability to breastfeed or
take liquid from the bottle

Coughs may be described in various ways. The pattern may be intermittent, constant, or quot;paroxysmal" - the latter meaning that the cough tends to come in "spells" or "attacks" separated by relatively cough-free intervals. Paroxysmal coughing is often associated with airway diseases such as croup or asthma, while a constant cough may indicate pneumonia. An intermittent cough may indicate a mild or early case of any of the above, but is more likely the body defending against something going on in the upper respiratory tract. When this is the case, position often makes a difference - the cough may appear when the child lays down in bed facilitating the drainage of nasal secretions into the throat ("post nasal drip"). In this situation, a decongestant - antihistamine preparation may help by dealing with the cause of the cough. Unfortunately, asthma also tends to worsen in the supine position, so a nocturnal timing by itself does not tell you what the cause is.

Another, perhaps more useful way of classifying coughs is by the way they sound (and by the other sounds associated with them):

Barking Whistling Juicy

Croup

A croup cough has a barking sound - like a dog or a seal. It indicates a narrowing in the windpipe below the vocal cords but not down in the lungs. It is caused by infections (usually viral), by allergies, and by certain anatomic changes in children prone to them ("spasmodic croup"). This cough is usually quite PAINFUL. It can also be frightening as the child with croup often awakens suddenly from a quiet sleep having an "attack" in which they can appear to be in a great deal of distress - both from the pain and from the difficulty breathing. The best way to handle these episodes is to talk quietly, try to reassure and calm the child, while providing humidity either by taking a walk outside (better, if the temperature is above freezing), or by turning a shower on and sitting in the steamy bathroom (O.K. if weather precludes the walk outdoors). This should break the attack within 20 minutes - if it doesn't, please call.

Another sound the child with croup may make is stridor. This is a hoarse raspy noise heard when the child INHALES. You will surely hear this during an "attack", but it should disappear when the coughing subsides and the child calms down. Rarely, the narrowing of the windpipe can get so severe as to be dangerous and require hospitalization. An early sign that this may be this case is CONTINUOUS STRIDOR which fails to go away between coughing spells. A child who has continuous stridor persisting more than 30-60 minutes after a croup attack needs to be seen right away. Likewise, stridor seen with no associated croup cough should also be promptly evaluated, especially if accompanied by drooling, fever, and shortness of breath.

Short of hospitalization for the severe case, treatment for croup is humidity. A cool mist vaporizer is best - either conventional or ultrasonic. These should be kept clean using bleach or as directed by the manufacturer on a regular basis. A decongestant may be of some benefit, especially if the croup is accompanying a cold. Tylenol or Ibuprofen will help the pain, and should be given even in the absence of fever.

Wheezing

A wheeze is not the sound of a cough, but rather a sound you should watch for often associated with a cough. It consists of a high pitched whistle or squeak usually heard best when you breath out or EXHALE. Sometimes this is very soft, and you will need to rest your ear against the child's chest to hear it. Other times it may be loud enough to hear down the hallway. Wheezing is a sign of narrowing in the small airways deep in the lungs. While it can happen to anyone as an isolated event, when a person is predisposed to repeated wheezing episodes it is called asthma. For a generation, physicians tended to shy away from making this diagnosis unless it got severe - instead using euphemisms such as "bronchitis" and "chest cold". In the past few decades mounting evidence that asthma is a progressive disease whose advance can be arrested by early and aggressive management has pushed us to change. Modern pediatricians diagnose as asthma anything, no matter how mild, which shares the wheezing physiology. Defined this broadly, about one in every six children (15%) have asthma! For most, however, it is a mild and very easily controllable disease. Still, wheezing is not something which should be tolerated. If you think you hear this for the first time, call immediately. If your child has done this before and you have medications for it, try them. If what you have is not successful at stopping the wheezing, however, the sooner you call the better.

Asthma

Productive Cough

Some coughs sound wet or "juicy". This usually means that the child is bringing phlegm or sputum up with the cough. Unlike adults who tend to spit this material out, children usually swallow it. This is fine, it does no harm in the stomach. Indeed, some cough medicines claim to have an quot;expectorant" to encourage this process. Unlike "suppressants", if it worked this wouldn't be such a bad idea. Once again, however, the claims tend not to be borne out in reality, and thus these things tend to be a waste of money.

A wet cough by itself should not be too concerning. It may represent post nasal drip or it may be a harmless, self-limited viral pneumonia. However, a wet cough not going away in 3-4 days or in combination with high fever (>102癋), shortness of breath, and/or chest pain may mean a bacterial pneumonia which will need antibiotics. Therefore, when a child has several of these signs in combination he or she should be seen.

A final note about coughs should regard duration. Cough accompanies a wide variety of short-lived, self resolving illnesses. Within the above guidelines it can be therefore safely "tolerated". A cough can also occasionally be the sign of a chronic problem. Because of this, please call about any cough which is persisting for more than 2 weeks.