312 Reprinted from Australian Family Physician Vol. 33, No. 5, May 2004

H John Fardy, MBBS, DRCOG,FRACGP, is a generalpractitioner,Gerringong, New South Wales,Chair, GeneralPractitioners’ AsthmaGroup, NationalAsthma CouncilAustralia, and Co-Chair,International PrimaryCare Respiratory Group.

THEME • Cough

A child with a cough – how common is that ingeneral practice? ‘Very’, is the simple answer.Fortunately, the diagnosis is usually straightforward.

Usually a cough is due to the current upper respira-tory tract infection (URTI) ‘doing the rounds’;sometimes, it is not so clear. The parent may be con-cerned that the cough is ‘funny’; it seems to bedifferent to other children’s URTI coughs, or is lastinglonger than the parent expects.

Significant causes of an acute cough need to be con-sidered: inhaled foreign bodies, aspiration, and infectionssuch as pertussis and pneumonia, as does the long listof possible causes of chronic cough in children (Table 1).

The coughClarifying the nature and duration of the cough throughfocussed history taking can assist enormously in diagno-sis. Is it wet or dry, nocturnal or daytime, exercise inducedor after feeding? Are there obvious triggers of the cough?

Children often present with a ‘persistent cough’ thatappears to be a simple URTI. Very specific questioningsometimes reveals that the child with a ‘persistentcough’ has had periods of a day or so where the coughand other URTI symptoms have lessened or passedcompletely, leaving the child quite well. This is immedi-ately followed by another ‘flare up’ of symptoms. Thisstory is not uncommon in households where there area number of children; it may reflect a series of recur-rent URTIs rather than the one persistent cough.

BACKGROUND A child presenting with cough iscommon in general practice. Usually the cough isdue to an upper respiratory tract infection,however, parents are often concerned that thecough may be asthma.

OBJECTIVE This article focusses on identifyingvarious causes of persistent cough, especiallyasthma.

DISCUSSION Significant causes of an acutecough need to be considered such as inhaledforeign bodies, aspiration, infections such aspertussis and pneumonia, and asthma. Clinicalhistory, followed by physical examination andconsideration of special investigations will guidethe diagnosis. Cough as the sole symptom ofasthma is unusual. There is usually associatedwheeze and shortness of breath. A family orpersonal history of atopic symptoms lend weightto the possibility of asthma. In children with asthma, physical examinationand even spirometry may be normal betweenepisodes. In some cases where asthma issuspected, a trial of bronchodilation with formalassessment of response may be appropriate.

A coughing child:could it be asthma?

Theme: A coughing child: could it be asthma?

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Asthma

Asthma is a common disease of childhood and also adisease commonly seen in general practice.1 For anumber of years the prevalence of asthma has seemedto be increasing in our community, so how is a generalpractitioner to handle a child presenting with a cough?Is it asthma or is it not?

The tried and true approach of clinical history, fol-lowed by physical examination and consideration ofspecial investigations will guide you through this difficultsituation. A facet of general practice that we sometimesfail to consider is the local epidemiological survey thatwe are constantly doing: ie. where we find ourselvessaying, ‘There’s a lot of it about...’ This may not besound methodologically, but the wise GP knows what iscommon in their community at that particular time.

Diagnosis

Asthma is usually diagnosed clinically on the pattern ofsymptoms and other associated features. Cough as thesole symptom of asthma is unusual. It is not really verydifficult to sort out a child who has a runny nose, lowgrade fever, is generally miserable, and has a wetsounding cough which persists for 3–4 days andfollows on from other members of the householdhaving similar symptoms. This is clearly a viral URTI. The clinical history of asthma is:• cough – usually associated with an audible wheeze

and breathlessness. Other features of history are:• family history of asthma, and• family or personal history of atopy, eczema or aller-

gic rhinitis.In younger children, where history is difficult to obtain,a trial of bronchodilator therapy may be reasonable withsome formal assessment of response.

The pattern of asthma

Another important feature of asthma is its pattern. Oneclassification of childhood asthma is:• infrequent episodic • frequent episodic, and • persistent asthma. This classification focusses on how often the asthmasymptoms occur, not the severity or cause of eachoccurrence of the asthma. The difference between‘infrequent episodic’ and ‘frequent episodic’ is that thereare intervals of more than 6 weeks between episodesand during that time the child is free of symptoms.

Physical examination

A thorough clinical examination is essential. Althoughwheeze is often heard, it is not unusual for a child tohave few, if any, clinical signs of asthma on examinationat the surgery when they are not having an acuteepisode. On occasion, clinical signs are found that willre-direct one’s attention. These may be the stigmata ofa congenital problem, evidence of a chronic diseasesuch as cystic fibrosis, or clinical signs of allergy such asthe clear nasal discharge of allergic rhinitis or flexuraleczema. Signs of airways obstruction from an inhaledforeign body or mediastinal mass should be considered.

Special investigations

Depending on the age of the child, office based spirome-try can be attempted. Some 7 year old children can dothe manoeuvres required for reliable spirometry; some10 year olds cannot. Asthma shows an obstructivepattern on spirometry with reversibility after bronchodila-tor (Figure 1). Normal spirometry does not exclude the

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Figure 1. Spirometry recording

Table 1. Causes of chronic cough in children

Infections (including viral, bacterial and tuberculosis)Aspiration (including reflux and foreign bodies)AsthmaEnvironmental irritants (including tobacco smoke and allergens)Chronic sinusitisCystic fibrosisCongenital heart disease

Theme: A coughing child: could it be asthma?

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diagnosis of asthma. The child may be well treated ormay be in an interval between episodes of asthma.

Imaging by means of chest X-ray or even an echocar-diogram may be considered when the history suggestsa cardiac cause for the cough and breathlessness.

How to proceed

Unless the diagnosis is clear and management is straight-forward, an empirical trial of bronchodilator therapy maybe appropriate. One of the greatest diagnostic instru-ments in general practice is time (see Case history). If achild has been given an adequate trial of bronchodilatorwith a delivery system that enables the medicine to getinto the lungs – and the GP is confident that the child isbeing given the medication as prescribed – and yet the sit-uation is still not clarified, referral may be required.Although asthma is common, uncommon things do occur.

ManagementThe treatment regimen for any patient with asthmadepends on the particular situation of that patient.Most benefit from:• education and encouragement about self management• provision of a written Asthma Action Plan (Figure 2),

and • regular review.Other important nonpharmacological measures are:• regular checking of device use (people lapse into

bad habits), and• constant encouragement about taking the medica-

tion as prescribed.When introducing medications, the big question iswhen to start an inhaled corticosteroid (ICS). This is acomplex and separate topic, but there is evidence thatsome children are on doses of inhaled corticosteroidsthat are unwise.2 If a daily dose of inhaled corticos-

Figure 2. The Asthma Action Plan

Case history – SaulSaul, 11 years of age, has been seen in the practice fora number of years. He is known to have asthma andallergies. He usually presents with an acute problemrather than for a planned review. As a result of thereactive nature of his visits (apart from the last one)the patient sees whichever GP is most readily avail-able (a different GP for each of the eight listed visits).What follows is a precis of the clinical record from April 2002:Presents with a recent history of persistent cough,wheeze, and runny nose over the past few days. HomePEFR recording shows decreased PEFR. On clinicalexamination he is wheezing audibly. This is treatedsymptomatically with salbutamol MDI and beclametha-sone (microfine) is started. He is reviewed the followingweek. By this time, Saul’s cough has settled, he hassome postnasal drip, his PEFR has improved substan-tially but he still has clear rhinorrhoea with postnasaldrip. He is given a trial of DemazinMay 2003: 2 week history of postnasal drip, fever,cough with no reported increase in bronchodilatoruse. His URTI was treated and a discussion was hadwith his parents about a trial of monteleukastJuly 2003: 10 day history of sore ears and sinusitis,amoxycillin and budesonide (nasal spray) 9 August 2003: temperature and dry barking cough;tender (L) maxillary sinus, PEFR slightly decreased,temp 38°C, start fluticasone/salmeterol 100/50 BD,cefaclor 375 mg BD and prednisone 20 mg daily taper-ing13 August 2003: settling well, continue cefaclor26 August 2003: still troubled by cough and sputum,PEFR back to normal? chronic sinusitis3 September 2003: for asthma review – has asthmaand nasal symptoms, very active but asthma does notinterfere with sporting activity, been on antibiotics for6 weeks for sinusitis, Current medications: fluticasone/salmeterol, mon-teleukast, nasal budesonide spray, prednisone,cephalexin Clinical examination and spirometry normalImpression: problem is chronic allergic rhinitis:referred to paediatric allergistOn skin prick testing Saul was found to be allergic todust mite, cat, cockroach and rye grass. He was inves-tigated for chronic sinusitis and a CT of the sinusesfound a polyp in his (R) maxillary sinus that is proba-bly contributing to his problems. His cough improvedconsiderably following treatment of his allergies andremoval of the polyp.

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teroid for a child of 250 µg of fluticasone, 400 µg ofbudesonide or 250 µg of beclomethasone-HFA is notimproving symptoms, it is worth reconsidering thediagnosis rather than just increasing the dose of ICS.

Asthma and...

There is nothing to say that a child cannot have asthmaalong with another disease that may present as acough or impact in some way on the child’s asthma.Most GPs have a clear idea of how a disease shouldprogress and it is always prudent to seek deviationsfrom what is expected. This unexpected pattern mayrepresent another diagnosis.

ConclusionThe child with a cough is usually reasonably straightfor-ward to diagnose and manage. Asthma is a commoncondition but it is not always the diagnosis. The oldtriad of careful clinical history, clinical examination andconsideration of special investigations, in associationwith the use of time as a diagnostic tool, should clarifythe diagnosis or lead to a referral.

Summary of important points

• Asthma is a common condition but it is not alwaysthe diagnosis in a coughing child.

• A careful clinical history is the key to diagnosis inasthma.

• Cough as the sole symptom of asthma is unusual.• A family history of asthma, and family or personal

history of atopy, eczema or allergic rhinitis, makes adiagnosis of asthma more likely.

• Physical examination may be normal in a child withasthma between episodes.

• The age at which children can perform spirometry isvariable.

• In younger children, a trial of bronchodilator therapywith formal assessment of response may be appro-priate if asthma is suspected.

Resource

The Asthma Management Handbook from the NationalAsthma Council (Australia). Available at: www.nation-alasthma.org.au has an excellent chapter on thediagnosis and management of paediatric asthma.

Conflict of interest: none declared.

References 1. Charles J, Pan Y, Britt H. Trends in childhood illness and

treatment in Australian general practice, 1971–2001. Med JAust 2004;180:216–219.

2. National Asthma Council. Inhaled corticosteroids: a practi-cal perspective. Available at: http://www.nationalasthma.org.au/papers/ics/asp/index.asp.

Theme: A coughing child: could it be asthma?

Email: h.j.fardy@unsw.edu.au AFP