My child won't stop coughing!

We have all no doubt noticed how coughing among children is practically the norm, especially in pre-schoolers. At any one time, research suggests that parents will report coughing in nearly a third of children. What’s more, the impact can be significant: poor sleep, reduced performance at school, parental anxiety, even a household awake all night long.

The most common cause is an acute viral Upper Respiratory Tract Infection (URTI) which healthy children experience several times each year. A quarter of these will continue to have a cough 2 weeks after the infection, possibly longer.

Assessment and treatment of cough  is an area under continuous review by the guiding medical bodies, most notably the British Thoracic Society.

Information on the internet about cough is generally inaccurate

As GPs we often view the internet as a double edged sword. It can be invaluable as a source of useful information for self-management, however misinformation is everywhere. A study was set up to investigate this revealing that out of 19 web pages identified giving information about cough, over half contained more ‘incorrect’ than ‘correct’ information, and only 1 was ‘mainly correct’. Choose your sources wisely!

Types of cough

 In General Practice we tend to consider cough in 2 groups:

Acute cough – less than 3 weeks duration, and Chronic cough, from 3 to 12 weeks, though this is a simplification.

Acute Cough

Acute cough is the type seen in the healthy child with a viral URTI. These tend to recover without any medical intervention. Symptoms can be eased with the use of inhaled steam or cough linctus. Complications are rare, and can be predicted to an extent by the presence of certain features including fever, breathlessness, and findings when examined such as crackles in the chest. Viral URTI is contagious and can spread through a classroom or playgroup. 

Particular examples of viral respiratory infections include Croup, where a young child develops a characteristic ‘barking’ cough, and bronchiolitis caused by a virus known as RSV, which is seasonal and again affects infants. 

Other causes of acute cough are Lower Respiratory Tract Infection (LRTI, commonly referred to as a ‘chest infection’), Allergy, Inhaled Foreign Bodies eg food or a small piece of a toy, and very rarely serious underlying disorders such as Cystic Fibrosis.

Chronic cough

Cough due to infection such as those seen in acute cough can sometimes become prolonged, lasting even up to 8 weeks. This is usually due to recovery after a virus, known as ‘post-viral’ cough, or sometimes childhood bacterial infections such as Whooping Cough. The commonest cause of the chronic cough remains respiratory tract infection. 

Whooping Cough itself is underdiagnosed. A study of school aged children presenting to their GPs with a cough lasting more than 2 weeks found that a third had strong evidence on testing of recent Whooping Cough infection. 90% of the children tested had completed their normal childhood vaccinations including the Whooping Cough vaccination. Whooping cough therefore is something we always consider when seeing a child with a prolonged cough.

Other causes of chronic cough are varied, and identifying them requires careful review of how symptoms developed, a thorough examination and sometimes investigations. 

Asthma can present as a cough alone, though more commonly s seen with wheezing and shortness of breath.

Gastro-oesophageal reflux, where acid and stomach contents leave the stomach and rise up the gullet causing irritation, is a rare cause.

Psychogenic cough is the term used to describe a cough that has become a habit. This usually occurs after a true URTI, however it lasts long after the infection has cleared. It is characterised by being dry and repetitive, and by fading in the evenings when the child is distracted. This sort of cough is safe but can only be diagnosed when other causes have been appropriately ruled out.

Serious causes of cough

These are rare, but as GPs we look out for certain ‘red flags’ that may prompt us to investigate further. As a parent it is wise to seek a review if any of the following symptoms are occurring in your child:

• Cough from newborn
• Chronic ‘wet ‘ cough
• Cough which started with a choking episode
• Cough when being fed
• Cough where the child is not growing well
• Coughing up blood
• Recurrent chest infections

When do we use antibiotics?

Antibiotics do not provide any benefit when used to treat a cough caused by a virus. These make up the majority of short duration acute cough and so where a child is otherwise healthy, antibiotics are not generally used. If the cough appears to be caused by infection and has lasted despite simple supportive measures, antibiotics may be required, especially where particular infective causes like Whooping Cough are suspected. The same is true if a child is particularly unwell, as this may indicate pneumonia where infection involves the tissue of the lung and not simply the airways. Antibiotics will also be used more readily where a child has other serious health problems such as heart disease or prematurity.

It is very important to remember that a cough caused by a simple virus can last as long as 3 weeks, however this in itself is not a reason to start antibiotics.

When is a cough not a cough?

Occasionally a child will come to see a GP with a cough which turns out to be ‘throat clearing’. This is rather different to a cough but not always immediately obvious. Throat clearing tends to occur with the mouth closed, and lacks the hard edge of a cough. 

A common cause for throat clearing is allergy, usually hay fever, and as such is typically treated with antihistamines and related medicines that can reduce mucus production that can irritate the back of the throat. 

Ask if you are uncertain

We can all expect to see our children have a cough from time to time. As always though, it can be difficult as a parent to gauge how your child is doing. If they are unwell and you are at all unsure, or simply want peace of mind, an assessment is generally straightforward with investigations only occasionally being required. We see children with cough daily, and recognise how troubling it can be. 

Best wishes

Dr James Hunt