Many problems in the treatment of cough in children
Explanation 1
Time frame criteria for diagnosis
Cough symptoms for more than 4 weeks, which is consistent with the criteria of the American College of Chest Physicians. The unification of criteria will facilitate future summary and analysis of pediatric chronic cough data as well as domestic and international communication.
Interpretation 2
Etiology varies by age
Common etiologies in infancy (< 1 week of age) include respiratory infections and post-infectious cough, congenital tracheal and pulmonary developmental abnormalities, gastroesophageal reflux, < span="">tuberculosis, and other congenital cardiothoracic anomalies, with congenital disorders being a special point for children in this age group. In addition to respiratory tract infections and post-infectious cough, the focus in early childhood (1 to week) is on upper airway cough syndrome, cough variant asthma, airway foreign bodies, gastroesophageal reflux, and tuberculosis. In the preschool years (3 weeks to 3 years), bronchiectasis must be considered in addition to this. The school age (6 weeks to prepubertal) adds the factor of psychogenic cough; adolescent-like adults, asthma and related diseases (including cough variant asthma, eosinophilic bronchitis, etc.), sinusitis and upper airway cough syndrome, and gastroesophageal reflux are the three main diseases causing chronic cough.
Interpretation 3
The Guidelines provide diagnostic clues
Respiratory tract infection and post-infectious cough. 1. a clear history of recent respiratory tract infection. 2. a cough that is irritatingly dry or accompanied by a small amount of white mucous sputum. 3. no abnormalities on chest X-ray. 4. normal pulmonary ventilation function. 5. cough is usually self-limiting. If the cough lasts longer than 8 weeks, other diagnoses should be considered.
In cough variant asthma, 1. persistent cough often strikes at night and/or early in the morning and is aggravated by exercise or cold air, with no clinical signs of infection. 2. diagnostic treatment with bronchodilators may result in significant relief of cough symptoms. 3. bronchial excitation tests suggest airway hyperreactivity. 4. history of allergic disease and its positive family history. Positive allergen testing may aid in the diagnosis.
The cough is worse in the early morning or when the position changes, often accompanied by nasal congestion, runny nose, dry throat, foreign body sensation, repeated clearing of the throat, and a few children complaining of headache, dizziness, and low fever. 2. There may be pressure pain in the sinus area, yellowish-white discharge from the sinus opening, follicular hyperplasia of the posterior pharyngeal wall, cobblestone-like, and sometimes mucus-like attachment to the posterior pharyngeal wall. 3. If the cough is caused by sinusitis, the corresponding changes can be seen on sinus X-ray or CT film.
Gastroesophageal reflux cough, 1. paroxysmal cough, mostly occurs at night. 2. cough mostly appears after eating and drinking, feeding difficulties, some children with epigastric or subxiphoid discomfort, burning sensation behind the sternum, etc. 3. infants can cause asphyxia in addition to cough. 4. can lead to delayed growth and development of the affected child.
Eosinophilic bronchitis, 1. irritating cough. 2. normal chest X-ray, normal pulmonary ventilation, no airway hyperresponsiveness. 3. relative percentage of eosinophils in sputum > 3%. 4. effective treatment with oral or inhaled glucocorticoids.
Psychogenic cough, 1. in older children. 2. predominantly daytime cough that disappears when focused on an event or at rest at night. 3. often associated with anxiety symptoms. 4. not associated with organic disease. psychogenic cough can only be diagnosed when twitchy disease is excluded and the cough improves after behavioral intervention or psychotherapy.
Interpretation 4
Diagnosis of chronic cough in children
Detailed history taking, careful physical examination, and routine chest X-ray are basic. The Guidelines list various tests including pulmonary ventilation function, bronchial excitation tests, sinus CT films, bronchoscopy, cytology of induced sputum or bronchoalveolar lavage fluid and isolated culture of pathogenic microorganisms, tuberculin skin test, serum total and specific IgE assay, skin prick test, 24-hour esophageal pH monitoring, etc. However, it does not mean that every child with chronic cough needs to have these tests. The Guidelines have prepared a practical diagnostic flow chart with the aim of providing pediatricians with a sequential approach to diagnosis, from simple to complex and from common to rare diseases. Finally, in the absence of clear etiologic hints, the principle of diagnostic treatment is to proceed in the order of upper airway cough syndrome, cough variant asthma, and gastroesophageal reflux cough.
Interpretation 5
Principles of management and therapeutic use
Emphasis is placed on identifying the cause of the disease and treating it for that cause. The expectations of the child’s parents should be attended to and taken into account. If the etiology is unknown, empirical symptomatic treatment can be administered first, but if the cough symptoms do not resolve after treatment, it should be re-evaluated. Cough suppressants should not be used in infants. The Guidelines emphasize the importance of post-treatment follow-up and re-evaluation, i.e., watch, wait and follow up.
Chronic cough with sputum should be treated as expectorant and not as a simple cough suppressant. H1 receptor antagonists such as chlorpheniramine, loratadine and cetirizine can be used to treat upper airway cough syndrome. Antimicrobial drugs can be considered for chronic cough with definite bacterial or mycoplasma or chlamydia infection. Calming anti-inflammatory drugs include glucocorticoids, 2-agonists, M-blockers, leukotriene receptor antagonists, theophylline and other drugs, mainly used for cough variant asthma and eosinophilic bronchitis. Gastric stimulants such as domperidone can be used in children with gastroesophageal reflux cough. Cough suppressants are not recommended for chronic cough especially before the cause is clearly identified, and codeine is prohibited for the treatment of all types of cough. The sedative effect of promethazine (finasteride) may mislead parents to overlook the adverse effects of the drug, including irritability, hallucinations, abnormal muscle tone, and even apnea and sudden death, and the WHO warns that promethazine should not be used as a cough suppressant in children under 2 years of age.
Explanation 6
Non-pharmacological treatment needs attention
Non-pharmacological treatments include avoidance of allergens, exposure to cold and smoke, including passive smoking; saline nasal irrigation for sinusitis; postural changes, food changes, and small and frequent meals for GERD cough; prompt removal of foreign bodies from the airway; discontinuation of medication for drug-induced cough; and psychotherapy for psychogenic cough. These non-pharmacological treatments are actually highly targeted etiological treatments.