After the white dew, the temperature difference between day and night increases, and many children have cough symptoms, some severe, some mild, some with runny nose, some with nasal congestion, and some with wheezing. The first thing many parents complain about when they come to see me is: My baby has been coughing for a month now, but it gets better and worse when he takes medicine. I fully understand the parents’ anxiety, because there are problems with the diagnosis, so there are problems with the treatment, and there are problems with the treatment, so the results are not satisfactory. I would like to remind parents that not all illnesses require infusions, and infusions are not the ultimate treatment for illnesses!
Coughing is a neurological reflex and is the main symptom of respiratory diseases. Coughing facilitates the discharge of airway secretions and pathogenic microorganisms and has a positive effect on clearing the respiratory tract; however, coughing also affects the patient’s rest and life and, more importantly, can cause the spread of airway inflammation. A persistent and violent cough also consumes physical energy and can cause destruction of the elastic tissue of the alveolar wall, inducing emphysema. Without explaining too much about cough caused by pneumonia, bronchitis and airway foreign bodies, I would like to share with you the following insights into the management of patients with non-specific chronic cough found in my clinical work.
First, let’s introduce the basics: 1. What is meant by chronic cough in children? 2. What causes can cause chronic cough?
Chronic cough in children is defined as a cough of more than four weeks’ duration, with cough as the main or only manifestation, and with no obvious abnormalities on chest radiographs. What are the causes of chronic cough in children? Answering this question is more complicated because there are so many causes, but in terms of the most common causes (top three) are (1) cough variant asthma CVA (2) upper airway cough syndrome UACS (3) post-infectious cough PIC.
Clinical features and diagnostic ideas of several non-specific chronic coughs
Causes
Clinical manifestations and diagnostic clues
Cough variant asthma CVA
(1) Persistent cough >4 weeks, usually dry, often with nocturnal and/or early morning onset, aggravated by exercise, exposure to cold air, no clinical signs of infection or ineffective after prolonged antimicrobial therapy.
(2) Significant relief of cough symptoms after diagnostic treatment with bronchodilators.
(3) Normal pulmonary ventilation with bronchial excitation tests suggesting airway hyperresponsiveness.
(4) History of allergic disease, as well as a positive family history of allergic disease. Positive allergen testing may assist in the diagnosis.
(5) Excluding chronic cough caused by other diseases.
Upper airway cough syndrome UACS
(1) Persistent cough for >4 weeks with white foamy sputum (allergic rhinitis) or yellow-green pus sputum (sinusitis), cough worse in the morning or with change of position, accompanied by nasal congestion, runny nose, dry throat with foreign body sensation and repeated clearing of the throat.
(2) marked hyperplasia of follicles in the posterior pharyngeal wall, sometimes with cobblestone-like changes, or with mucus-like or purulent secretions attached.
(3) Antihistamines, leukotriene receptor antagonists and nasal glucocorticoids are effective for chronic cough caused by allergic rhinitis, while chronic cough caused by septic rhinitis requires antibacterial drug treatment for 2-4 weeks
(4) Nasopharyngoscopy, lateral head and neck radiographs, sinus radiographs or CT films may be useful for diagnosis.
Post-infectious cough PIC
(1) Recent history of definite respiratory tract infection
(2) Cough lasting >4 weeks, with an irritating dry cough or with a little white mucous sputum
(3) Chest radiography without abnormalities or showing increased texture in both lungs
(4) Normal pulmonary ventilation or transient airway hyperresponsiveness
(5) Cough is usually self-limiting; if the cough lasts longer than 8 weeks, other diagnoses should be considered
(6) Exclusion of other causes of chronic cough
Allergic cough AC
(1) Cough lasting >4 weeks with an irritating dry cough
(2) Normal pulmonary ventilation and negative bronchial excitation test
(3) Increased sensitivity of cough receptors
(4) History of other allergic diseases, positive allergen skin test, elevated serum total IgE and/or specific IgE
(5) Exclusion of other causes
Referring to the latest edition of the “Guidelines for the diagnosis and treatment of chronic cough in children”, the four more common clinical causes of chronic cough are listed in a table so that families can easily compare themselves.
In fact, it is easy to see that most of the children who are diagnosed by doctors as having “bronchitis” with poor results are actually misdiagnosed, and the repeated use of antibiotics and cough suppressant medications in accordance with bronchitis has proven to be ineffective. So the question is, how do you determine what is wrong with my child? How do you treat it?
In fact, I came to a general conclusion by asking detailed questions about the condition, paying attention to every detail (such as the child’s age of onset, season of onset, the onset of cough within 24h, accompanying symptoms, etc.), gradually screening each child’s cough according to its clinical characteristics and diagnostic ideas, refining relevant tests, giving diagnostic treatment after excluding the possibility of specific infections and airway foreign bodies, and giving feedback on the treatment effect through the patient. The final diagnosis is reached through patient feedback. It is important to note that diagnostic treatment is important because we are not yet able to complete all the relevant tests in our hospital. It is important to follow up and re-evaluate children with chronic cough.
Finally, I also briefly introduce the treatment options for common related diseases in the form of a chart. However, I would like to emphasize three points: 1. The cause of the disease should be clarified as much as possible in order to prescribe the right medicine (routine use of antibiotics + cough medicines is an irresponsible practice by professional pediatricians). 2. Follow-up and re-evaluation after treatment is very important, so I hope that families will provide timely feedback on the effectiveness of the treatment to facilitate adjustment of the treatment plan and also provide experience for doctors to improve the level of diagnosis and treatment. 3. For children with chronic cough, attention should be paid to removing or avoiding exposure to Allergens, smoke and other environmental triggers and aggravating factors should be avoided.
Disease
Treatment options
Cough variant asthma CVA
(1) Oral β2 agonists such as procaterol (Meprobamate) and salbutamol (albuterol) can be given as diagnostic treatment for 1-2 weeks
(2) Tolterol (Asthma), a transdermal β2 agonist, can be used to help diagnose CVA if cough symptoms are relieved.
(3) Once CVA is clearly diagnosed, long-term standardized treatment of asthma with inhaled glucocorticoids, the M-blocker ipratropium bromide (cortisone), the phosphodiesterase inhibitor dihydroxypropyl theophylline (asthma) or/and the oral leukotriene receptor antagonist montelukast (cisplatin) for at least 8 weeks
Upper airway cough syndrome UACS
Different regimens depending on the upper airway disease causing the child’s chronic cough
(1) allergic (allergic) rhinitis: antihistamine cetirizine, loratadine (Coretan), nasal spray glucocorticoids, or a combination of nasal mucosal decongestants (oxymetazoline and cyclozoline) and leukotriene receptor antagonists
(2) Sinusitis: give antibacterial drugs, such as amoxicillin + potassium clavulanate, cefprozil, azithromycin, etc. orally for at least 2 weeks, supplemented by nasal irrigation, nasal local decongestants or expectorant drugs
(3) Adenoid hypertrophy: according to the degree of hyperplasia, mild to moderate cases can be treated with nasal spray of glucocorticoid
Hormone combined with leukotriene receptor antagonist, 1-3 months of treatment and observation waiting, ineffective surgical treatment can be taken
Post-infection cough
PIC
PIC is usually self-limiting; in severe cases, treatment with oral leukotriene antagonist montelukast (cisplatin) or inhaled glucocorticoids may be considered
Allergic cough
AC
Treatment with second-generation antihistamines cetirizine or loratadine, mast cell membrane stabilizers such as sodium cromoglycate, and glucocorticoids is advocated.
PS: Hormones are also drugs with powerful anti-inflammatory, anti-toxic, and anti-allergic effects. It is easy to see that hormones are often used in the treatment of chronic cough, whether as topical sprays, nebulized inhalations, orally, or even intravenously. The principle of hormone use is individualized, with the smallest effective dose maintaining the best therapeutic effect. Through long-term comparative studies abroad, it has been found that the regular use of nasal spray hormones and nebulized inhaled hormones will not cause growth restriction in the recipients. Therefore, it is completely unnecessary for some family members to talk about hormones or even refuse to use them altogether. As long as hormones are used regularly under the guidance of professional doctors, they are safe!