History and examination guide diagnosis
CHILDREN WHO COUGH are frequently seen in general practice. Determining what is a “normal” cough from that
which is abnormal can be challenging for both parents and primary care teams. Cough is a protective reflex and children
who have no evidence of illness may cough an average of 11 times over a day.1
Children are not small adults and the causes of cough in children may be different to the causes in adults.2,3
The assessment of children with cough, particularly when the cough is chronic, should be carried out in a systematic
way. This should assist with the formation of an accurate diagnosis whenever possible and then allow successful management
of the cough.
In New Zealand, bronchiectasis and pertussis continue to be prevalent, especially in the upper North Island. This is
despite the fact that worldwide the incidence of these diseases is declining. Factors such as over-crowding, a lower socio-economic
environment and late presentation to healthcare facilities are thought to play a significant role in the continuing prevalence
of these diseases in New Zealand.
History and examination guide diagnosis
Acute cough is likely to be caused by a viral upper respiratory tract infection
The majority of children with acute cough will have a viral upper respiratory tract infection (URTI) and cough will
be just one of the several ubiquitous symptoms. In these children, a clinical diagnosis of a viral URTI can be made and
the role of symptomatic management outlined to the parents.
It is important however, not to overlook any symptoms that may suggest a more serious but less common cause for the
cough. Also plan a review if the child deteriorates or the cough persists. Asking a question such as “Can you tell
me about the cough?” will often help reveal other information that may point to red flags in the history (see sidebar “Detecting
serious illness in children”).
Detecting serious illness in children4,5
It is estimated that less than 1% of children presenting to general practice will have a serious illness. The role
of the GP is therefore to detect and diagnose these very ill children while also appropriately reassuring parents of
children who are less unwell. Complicating this further is that the initial consultation may be at an early stage in
an illness when the diagnosis is not clear and there is little indication of the potential severity. Time can be a
useful diagnostic tool in general practice. Provide a “safety net”, particularly if a diagnosis has not
been reached.6 This may include verbal, or preferably written, information for parents that outlines symptoms
or signs of worsening illness, instructions on how to access after hours care and a clear plan for follow-up.
Although the majority of children with an acute cough are likely to have a viral URTI the possibility of a more serious
problem should be considered. History and examination may reveal the presence of red flags that can help to determine
which children require further investigation or referral.
Red flags in children who cough:7
- Neonatal onset of cough
- Cough during feeding
- Sudden onset of cough or a history of choking that may suggest foreign body inhalation
- Chronic, wet cough with sputum production
- Continuous, unremitting or worsening cough
- Presence of associated features such as shortness of breath, hypoxia or cyanosis, rapid breathing, stridor, night
sweats, weight loss or haemoptysis
- Signs of chronic lung disease e.g. chest wall deformity, digital clubbing, poor growth
- Parental concern that persists despite reassurance
- Clinician’s instinct
For guidance on assessing a child with fever see “Identifying
the risk of serious illness in children with fever”.
Listen to the concerns of parents
Cough in children, regardless of the underlying reason, can cause significant distress, disruption of daily activities
and a lack of sleep for both the child and the parents. Ask open questions following the standard “FIFE” format
- Feelings: What are your concerns?
- Ideas: What do you think is the cause of the cough?
- Function: How is the cough affecting your child and yourself?
- Expectations: What do you think is needed to help resolve the cough?
Responses to these questions should help uncover parental concerns, suggest areas requiring further direct questioning
and guide the type and range of advice given. In many cases the answers may also reveal the likely diagnosis.
Consider personal, family history and environmental factors
Aspects of the child’s personal, family and social history may provide clues to the underlying reason for a cough.
- The child’s personal medical history e.g. a history of atopy, recurrent infections, poor growth
- The family history (particularly a history of any respiratory conditions)
- Any exposure to environmental factors e.g. cigarette smoke, pets, damp living conditions
- The immunisation status of the child and others in the family
- Tuberculosis (TB) if the family is from a high risk country or if there is any history of contact with a person with
This information may not always be required e.g. in a child with a likely URTI or the information may already be known
e.g. a patient who regularly consults the same GP at a practice. Take the opportunity to measure height and weight, to
check on overdue recalls, to provide advice about a smoke-free home or to check oral health.
How long has the child been coughing for?
Cough in children can be categorised as:
- Acute cough – lasting for less than two weeks
- Sub-acute or persistent cough – lasting two to four weeks
- Chronic cough – lasting for more than four weeks
Acute and sub-acute cough in children is usually due to a viral respiratory tract infection that will spontaneously
resolve within one to three weeks in 90% of children.8
Other serious causes of acute cough e.g. pneumonia, pertussis, foreign body inhalation should however, be considered
and excluded if possible. The acute cough may also indicate the start of a chronic cough condition. In some cases, chronic
cough lasting more than four weeks is caused by recurrent viral infections over winter, each incompletely resolving before
the next infection. A careful history should distinguish this from true chronic cough. Children with chronic cough are
likely to require review as the underlying cause of the cough may not initially be clear and the type of cough may change
It is also important to ask about the onset of the cough. A cough associated with a very sudden onset or a history of
choking may suggest inhalation of a foreign body, particularly in younger children.
What does the cough sound like?
The character or the quality of the cough may in some cases suggest a specific cause, termed as classically recognised
cough (Table 1). However, in practice this may have limited value. Unless the child is coughing in the waiting or consulting
room, the GP is dependent on a description of the cough from the parents.
Other causes should not be excluded on this basis alone e.g. a “pertussis-like” paroxysmal cough may be
due to Bordetella pertussis but could also be caused by a viral infection such as adenovirus, parainfluenza virus, respiratory
syncytial virus (RSV) or mycoplasma.
The age of the child may also alter the character of cough e.g. infants aged under six months with pertussis do not
|Table 1: Classically recognised cough and underlying causes (adapted from Chang at al,
||Suggested underlying disease process
|Barking, brassy or croupy cough
||Acute or spasmodic croup, tracheomalacia (tracheal collapse), habit cough (psychogenic)
|Honking cough (usually absent during sleep)
|Paroxysmal (with or without inspiratory “whoop”)
|Staccato cough in infants
|Chronic wet cough in mornings only
||Suppurative lung disease
|Cough associated with wheeze and breathlessness
|| Consider asthma
Is the cough dry or wet?
Determining whether the cough is dry and irritating or wet and “rattly” may help to diagnose the cause,
particularly if the cough is chronic. A chronic cough with purulent sputum in a child requires further assessment as it
always indicates underlying disease.9
A wet cough in older children and adults is often called a “productive” cough, but this term has limited
value for many younger children as they tend to swallow sputum rather than cough it up, often resulting in vomiting. It
may be more useful to ask if the child has vomited.
Research has shown that subjective reporting of a wet cough by parents is consistent with findings of airway secretions
at bronchoscopy.10 A wet cough was shown to be always associated with an increase in airways secretions, however
a dry cough did not always signify an absence of secretions. In addition, a dry cough may be reported early in an illness
and then evolve into a wet cough as secretions increase.10 Parents should be made aware of when it is appropriate
to bring the child back for review and also advised about signs that may suggest worsening illness (see below for guidance
on information that can be given to parents).
Does the child cough at night?
Sleep generally suppresses “normal” and habit cough (see box “Habit cough syndrome” below)
and although nocturnal cough is often associated with asthma, this is less likely for children in the absence of any other
associated symptoms such as wheeze.
Nocturnal cough is often a reason for presentation for medical attention because the cough may cause significant anxiety
for the parents, be more noticeable and disturb sleep for the whole family. Although nocturnal cough may be the symptom
that drives the parent to bring the child to the GP, evidence suggests that parental reporting of nocturnal cough can
How old is the child?
The age of the child when the cough started may be important in helping determine the diagnosis. Any unexplained persistent
cough that begins in the neonatal period (the first 28 days of life) requires investigation and usually indicates significant
disease (Table 2).7 Discussion with, or referral to, a paediatrician is usually recommended.
Foreign body inhalation
Once children are old enough to put small objects in their mouths, the possibility of aspiration of a foreign body should
be considered. Most cases of foreign body aspiration occur in children aged less than four years. Ask parents about the
potential for foreign body aspiration, such as access to any small object or consumption of small, smooth foods (e.g.
peanuts, raisins, grapes). If foreign body inhalation is suspected then the child should be referred to secondary care
for further investigations.
|Table 2: Neonatal causes of chronic cough9
|Aspiration (usually milk)
A moist cough that follows feeding
Irritability, arching or choking after feeds. Usually in a child with an underlying congenital cause such as tracheo-oesophageal
fistula or laryngeal cleft. Only rarely in a child with normal anatomy and development.
|Congenital malformation: compression of airway or tracheobronchomalacia
Stridor, wheeze, cough
Recurrent respiratory infections
||Varied presentation - respiratory symptoms (often cough), gastrointestinal complications (intestinal
and pancreatic), failure to thrive
|Primary cilial dyskinesia
||Chronic, persistent rhinitis since birth
|Lung infection in utero or in the perinatal period
||Chlamydia, cytomegalovirus, respiratory syncytial virus
Are there any associated symptoms?
Does the child only have a cough or are there other symptoms? The presence of any associated symptoms may help determine
the underlying cause of a cough. Examples may include:
- A cough associated with runny or blocked nose, sore ears or throat, fever or irritability suggests viral infection
- A cough that started after an episode of choking strongly suggests foreign body inhalation
- A cough that is associated with wheezing and breathlessness may suggest asthma
- A history of night sweats and haemoptysis in a “high-risk” child could suggest tuberculosis
What triggers the cough?
Ask about any factors that may trigger the cough e.g. exercise, excitement or cold air. Also ask about environmental
- Is the house smoke-free?
- Are there family pets?
- Is the house damp?
Cough that only appears in specific situations e.g. before speaking, with stress, at school, that disappears at night
and that is reproducible upon request may be a habit cough (see box “Habit cough syndrome”).
Habit cough syndrome7,9,12,13
Habit (psychogenic) cough is estimated to be the cause of persistent cough in children in 3–10% of cases. Diagnosis
should only be made after other causes have been excluded, such as a transient or chronic tic disorder or Tourette’s
syndrome. The typical characteristics which may suggest this diagnosis include:
- A dry, harsh, often honking, repetitive cough. In some cases however, it may be more a “clearing of the throat”
- An initial association with an upper respiratory tract infection
- A cough that tends to decrease during enjoyable activities and be absent during sleep
- A cough that may occur before speaking and at times of stress and increases in the presence of parents and teachers
- The cough may be disruptive to others while the child appears indifferent to it
- The cough is usually able to be reproduced upon request
- There may be secondary gain from the cough such as increased parental attention or absence from school
- A history of psychosocial problems such as abuse, anxiety, school phobia or depression
Management includes identification of, and assistance with, any problems at home or school, behavioural intervention
and speech-language therapy.
The clinical examination of a child who presents with cough should include:
Normal respiratory and heart rates vary with age
An assessment of respiratory and heart rate can give good information about how unwell a child is. The table below
gives a range of normal values that are appropriate at varying ages during childhood.
- An assessment of how “well” the child is
- Temperature, hydration, pulse rate and respiratory rate (see sidebar “Normal respiratory and heart rates vary
- Height and weight
- Ear/nose/throat examination – primarily checking for signs consistent with upper respiratory tract infection. N.B.
Cough can be triggered in some people by an irritation of the auricular branch of the vagal nerve e.g. by wax or a foreign
body in the auditory canal.
- A check for clinical signs suggestive of allergy e.g. allergic “shiners” (dark circles under the eyes),
nasal speech, eczema
- Chest examination including observation e.g. accessory muscle use, indrawing, chest deformity and chest auscultation
for localised or generalised chest signs
- A check for digital clubbing
Best practice tip – In some young children it can be difficult to get them to
take breaths that are deep enough to give reliable findings on auscultation. Asking children to “pant like a big
dog” with their mouth open or to “huff” (breathe out forcibly) may reveal chest signs that are not apparent
with normal shallower breaths and also may stimulate a cough which enables the quality (dry or wet) to be heard.
Investigations for cough
Investigations are not required for children with acute cough who are likely to have a diagnosis of a viral URTI.
Sputum culture may be indicated in an older child with a chronic, wet cough. Most young children swallow their sputum
and are unable to produce a sample that is of sufficient quality to provide useful results.
Spirometry is indicated for children with chronic, dry cough who are old enough to master the technique (usually school-age
children).13 Spirometry may give information about airway obstruction and responsiveness to a bronchodilator.
N.B. If the child is asymptomatic and normal results are obtained, this does not exclude a diagnosis of asthma.14 Peak
flow is generally not used as a diagnostic tool for asthma as it has not been validated for this use and results are not
A chest x-ray should be considered if a child has a:
- Chronic cough of unknown aetiology
- History of aspiration (acute onset of cough, choking episode)
- Persistent signs on chest examination (deformity, focal findings on auscultation)
N.B. A normal chest x-ray does not exclude the presence of an inhaled foreign body.
Management of acute cough in children
The majority of children who present to general practice with acute cough will have a viral URTI. In children without
symptoms and signs of a specific serious underlying disease process, the recommended approach is to watch, wait and review.
Investigations are not usually required and treatment should be aimed at providing symptomatic relief (see “Do
cough and cold medicines work in children”).
Parents should be given information that enables them to make an informed decision
about if and when to bring the child back for review. This may include information on:
- The symptoms to expect
- The duration of these symptoms
- Symptoms and signs of worsening illness
- The plan for follow up
- The potential hazards and ineffectiveness of cough and cold medicines
Among the many children who present with acute cough, it is important to identify the child who may have a predominantly
lower respiratory infection and be unwell, with fever, tachypnoea, decreased oxygen saturation and chest signs. Antibiotics
may be indicated depending on the diagnosis and a follow up appointment should be arranged to check for clinical improvement
and resolution of chest signs. If the child is very unwell, referral for further assessment, chest x-ray and treatment
in a secondary care setting may be required.
Management of chronic cough in children
Management of chronic cough depends on the underlying diagnosis. If symptoms and signs found in the history and examination
suggest there is a specific underlying disease causing the cough, then treatment should be aimed at this condition. In
some cases, the child may need further investigations before a diagnosis can be made.
Causes of chronic cough in children include:7
- Persistent respiratory infection including post viral cough, chronic bronchitis, bronchiectasis, cystic fibrosis,
pertussis and tuberculosis
- Passive exposure to cigarette smoke
- Recurrent aspiration e.g. secondary to reflux, congenital abnormality
- Habit cough
- Upper airway cough syndrome
- Gastro-oesophageal reflux
- Cardiac causes e.g. congestive heart failure, congenital heart disease
- Medication e.g. rarely ACE inhibitors
Indications for referral
Referral indications for a child with cough include:
- Cough that does not resolve despite simple management
- Suspected foreign body aspiration
- Recurrent pneumonia (or chest signs that do not resolve)
- Suppurative lung disease
- Congenital lung lesions or disease
- Immunodeficiency states
- Cardiac abnormalities