Cough, cough, cough: What to do and when to worry

If you look down my schedule in the winter time, the most common complaints you will see are fever and cough. I have already addressed fever on this site so now it’s time to address coughs. So many things can cause a cough. Just discussing the common causes will be a long post, but here it is!

Children get many illnesses in the winter that cause a cough. Parents often worry that the cough is a sign of something ominous. Furthermore, coughs last so long that they are often distressing to both the child and the parent, as well as the teacher, classmates, friend’s parents…etc. This post will breakdown the common causes of coughs, how to help your child and when you should worry.

What is a cough?

Coughing occurs when something other than air gets into the airway below the vocal cords.  The upper airway starts at the back of the nose and moves down to the vocal cords. The lower airway includes the trachea, the right and left bronchus which leads to each lung, the small tubes of the lungs called bronchioles, and the air sacks. Because the airway prefers air instead of anything else (like mucous), as soon as something gets into the lower airway, it is quickly expelled. (Take a look at this animated video showing how a cough occurs in the body.) Therefore, coughs can occur due to any foreign object anywhere along the airway. Coughs in children are most commonly due to post nasal drip. Mucous drains from the upper airway into the lower airway. However, some coughs originate in the lower airway and it’s important to differentiate.

What causes a cough?

The list of what causes a cough is a mile long and would take many posts to cover. For the purpose of this post, I am going to cover the common infectious causes that we see in children. A careful history and physical exam usually lets the doctor know what the cause may be. Sometimes an xray may be needed. It is very helpful for the parent to be able to describe the cough. Here is a description of some different cough sounds.

  • Common Cold: Colds are viral illnesses that cause mucous production in the upper airway. The cough occurs from post nasal drip of the mucous. They last about 10 days but the cough may linger beyond that.
  • Viral cough: This is similar to a cold but the lower airway is infected by the virus. This means patients will not have the typical runny nose or congestion that occurs with a cold. Again, this cough can last for weeks.
  • Influenza: The flu is a severe viral infection that causes fever, body aches, fatigue, headache, sore throat and cough. There is usually less mucous production in the upper airway with the flu compared to a cold. Also, the fever is usually higher compared to the common cold.
  • Pneumonia: This is probably what parents worry about the most. Pneumonia is not usually present at the start of a cough or cold as it is frequently a secondary infection to the cold virus. This is because the sticky environment that the cold virus creates is a perfect home for bacteria. The infection, and pus it creates, fills the air sacks, making it hard to breathe and causing a high fever. If your child has any difficulty breathing, seek medical care right away. Pneumonia is also caused by viruses so not all pneumonia infections require antibiotics. Furthermore, older kids and teens can get walking pneumonia which is caused by the bacteria Mycoplasma. Your child’s doctor may want a chest x-ray to determine if your child has pneumonia and what type they may have.
  • Bronchiolitis: Caused by RSV, bronchiolitis is an infection of the bronchioles, or small tubes in the lungs. The extreme amount of mucous production plugs the airway causing cough, distress with breathing and sometimes wheezing. RSV is more severe for young babies so please take your child to the doctor right away if you suspect it.
  • Croup: Croup is a viral illness that causes swelling in the upper airway. The cough is described as barky and some children will make a sound when breathing in known as stridor. Placing the child in a steamy bathroom or going out into the cool night air can calm a croupy cough.
  • Sinusitis: The diagnosis of sinusitis is made after a cold and cough have been present for at least 10-14 days. The diagnosis is not made for a child that has a dry lingering cough that is gradually getting better, which is the typical pattern. The diagnosis should be made in the setting of continued congestion, worsening symptoms after 2 weeks, headache or face pain, and possibly new onset of fever. Even if your child has symptoms of sinusitis, it will often get better on its own, so there is not a rush to start antibiotics. However, it is a good idea to discuss treatment options with your child’s doctor.
  • Whooping cough: Sadly we still diagnose this dangerous vaccine-preventable infection that is caused by the bacteria Bordatella pertussis. The infection starts with mild cold symptoms but eventually progresses to a severe spasmodic cough. Young babies and children will create the classic whoop sound when breathing in following a coughing fit but older children may not. Furthermore, babies may stop breathing all together. Older children will cough so hard that they will throw up following the coughing fit. Unfortunately, whooping cough can be fatal at worst and cause 3 months of cough at best, so make sure your whole family is up to date on their whooping cough vaccines.
  • Bronchitis: Bronchitis is inflammation in the bronchus, or large tubes, of the lower airway. While it is a common diagnosis in adults, especially smokers, it is not common in young children. The symptoms typically overlap with either a cold or asthma. The most common cause of bronchitis is a viral infection so antibiotics are not indicated unless there is a secondary pneumonia that has developed.
  • Asthma: While asthma is not an infection and is going to require its own post, the most common trigger for asthma is a cold. Therefore, if you think your child is wheezing during their illness, it is best to see the doctor. Some chronic coughs may actually be cough-variant asthma even in the absence of wheezing so this is something your doctor may consider if your child has a chronic cough lasting more than 4 weeks.

How should you treat a cough?

If your doctor has prescribed antibiotics for pneumonia, a sinus infection or whooping cough, give the whole course as prescribed. Because most causes of coughs are viral, there isn’t anything we can give to make it go away any faster and antibiotics are not appropriate. But there are things you can do to comfort your child and ease their symptoms.

  1. Clear the airway by using saline in the nose
  2. Keep secretions looser by maintaining good hydration
  3. Soothe the throat with warm fluids and honey (only over 1 year of age)
  4. Use cough drops for children over 4 years old
  5. Use steam or a humidifier to keep the nasal passages from clogging up
  6. Avoid smoke exposure
  7. Only give decongestants or cough suppressant medications to children over age 6 and only give if it seems to temporarily help the symptoms

When is it time to worry?

As already mentioned above, if your child is coughing longer than 10 days, has any distress with breathing or chest pain, seek medical care. Watch for rapid breathing, retractions (when the muscles sink between the ribs) and extra labor with breathing. Listen for sounds with breathing like stridor (whistle sound with inspiration) or wheezing (whistle sound with expiration). Sometimes parents hear a whistling sound that they think is wheezing but is actually from breathing through a blocked nose. Also, parents often worry in a small child that they can feel a rattle in the chest. This is the child breathing through mucous that is most likely in the upper airway. When in doubt, take your child to see the doctor and if your child is getting tired from breathing, can’t seem to catch their breath or looks blue around the lips, call 911.

Overall, if your child is coughing but is not having any difficulty breathing and has had a normal exam by the doctor, don’t worry. It is likely to pass. However, if things get worse or the breathing looks labored, seek medical care.