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3«COyyOMUM-JMTMaL» #27№6)), 2023 / MEDICAL SCIENCES
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Tarnavska S.I., Shakhova O.O., Zapotochna V.O., Ovchinnikova T.S., Klym L.O., Dushkevych O.I.
Department of Pediatrics and Children's Infectious Diseases Bukovinian State Medical University, Chernivtsi, Ukraine DOI: 10.24412/2520-6990-2023-27186-39-41 DIFFERENTIAL DIAGNOSIS OF RECURRENT COUGH IN CHILDREN
Introduction.
"Respiratory pathology", "Acute respiratory infections" (ARI), "cough" are the terms most often used by pediatricians. There is a logical explanation for this: respiratory pathology dominates the structure of childhood morbidity, ARI tops the ranking of infectious diseases in the pediatric population, and cough is the most common complaint that parents of young patients address pediatricians or family doctors with. The main tool to change these disappointing statistics is the implementation of new progressive recommendations for the treatment of children with cough-related diseases in the practice of pediatricians.
Key words: cough in children, recurrent cough, differential diagnosis of cough in children.
Respiratory tract pathology in children remains the most pressing problem in modern pediatrics. Despite the fact that the main category of patients in primary care are patients with respiratory disorders, there are a number of unresolved issues regarding the diagnosis and treatment of these conditions. This is especially true for young children, as the anatomical and physiological features of their respiratory system make it difficult to interpret the symptoms of respiratory diseases, which leads to erroneous or delayed verification of the diagnosis, and thus to the prescription of not always correct treatment [2].
Material and Methods. To analyze the data of Ukrainian and foreign articles by keywords: cough in children, recurrent cough, differential diagnosis of cough in children.
Results and discussion. According to the Ukrainian Institute for Strategic Studies of the Ministry of Health of Ukraine, respiratory diseases are the most common among children. In the structure of disease prevalence among children under 17, respiratory pathology accounts for 54.2%, which is significantly higher than the rate of diseases of other organs and systems [1].
Recurrent cough (RC) - (not associated with ARI) repeated (2 or more times a year) episodes of cough other than those associated with ARI per year) episodes of cough other than those associated with ARI; lasts longer than 7-14 days/episode. If the periods of remission are short, recurrent cough can be difficult to distinguish from persistent chronic cough [3].
Recurrent cough is a common problem that parents often visit family doctors with. There are many causes of recurrent cough. Although most cases of recurrent cough are benign, serious illnesses can also manifest themselves in this way.
Although "cough" is an accurate symptom, its severity is often not reported objectively. Studies using nighttime audio recordings have shown that parental reports of coughing do not correlate well with the frequency, duration, or intensity of the actual cough. A study in which cough was measured objectively showed that healthy children aged 10 years on average have 10 cough episodes (ranging up to 34) in 24 hours, mostly during the day. This number increases during respiratory infections, which in healthy children can occur 5-8 times a year, lasting 7-9 days. This causes an
additional 50 days of coughing per year. A cough without wheezing is associated with environmental factors, including humidity in the home and air pollution, and is also closely related to socioeconomic status. Parental smoking is associated with an increased prevalence of chronic cough, which is 50% in children under 11 years of age who have two smoking parents [6].
Causes of RC:
■ ALLERGY AND REACTIVE AIRWAY DISEASE (asthma, allergic or vasomotor rhinitis)
■ INFECIONS (recurrent viral respiratory infection, pneumonia, chlamydial infection, mycoplasmal infection, pertussis or pertussislike syndrome, tuberculosis, psittacosis, fungal infections (histoplasmosis, blastomycosis, coccidioidomycosis), parasitic infestation (visceral larva migrans, ascariasis), sinusitis)
■ FOREIGN BODY ASPIRATION
■ IMMUNODEFICIENCY DISORDERS
■ CONGENITAL MALFORMA TIONS (tracheoesophageal fistula, laryngeal cleft, vascular ring, bronchiogenic cyst, pulmonary sequestration, immotile cilia syndrome)
■ CYSTIC FIBROSIS
■ BRONCHIECTASIS
■ ENVIRONMENTAL IRRITANTS (cigarettes smoke, house dust)
■ CARDIACFAILUREDRUGS (angiotensin-converting enzyme inhibitors, 3-Adrenergic antagonists)
■ AIR WA Y ENCROA CHMENT (mediastinal tumours, mediastinal adenopathy, pulmonary tumours)
■ PSYCHOGENIC COUGH
The initial examination of children with cough at the first visit involves a thorough history and a focused physical examination to decide whether to provide further treatment.
Describing the characteristics of a child's cough is crucial in the health care setting. Questions about age of onset; wet or dry cough; triggers, frequency and timing of cough; and the presence of associated symptoms should be answered. Age of onset and duration of symptoms are important factors. Determining the frequency and possible progression of the cough helps to assess whether the child has episodes of acute cough resolution or has a potentially serious underlying respiratory disease. It is possible to ask parents to keep a
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cough diary in which they record the frequency, duration of cough and possible provocative factors. Children who have a continuous cough lasting more than four weeks should be re-evaluated for serious underlying conditions. Timely intervention can limit the progressive harm and burden associated with conditions such as bronchiectasis, aspiration lung disease, and foreign body inhalation [6].
Ideally, the clinician should be able to listen to the child's cough in the clinic. If the child is unable to perform the coughing maneuver in the clinic, you can also ask the caregiver to make a video of the child's cough. A targeted respiratory examination, especially one that looks for digital clubbing, hyperinflated chest, Harrison sulci and adventitious breath sounds, can guide further evaluation in a child with RC.
About half of children with asthma develop symptoms before the age of 3. A typical history describes recurrent episodes of wheezing and/or coughing caused by an upper respiratory tract virus (URTI), exercise, or weather changes [8]. What used to be called "cough variant of asthma" is now more commonly called eosinophilic bronchitis. Treatment consists of inhaled corticosteroids, to which this form of cough is usually very sensitive. Cough may be the only symptom of the full asthma syndrome, so a thorough history should be taken. In most cases, no additional examination is required. In other cases, examination X-ray of the OHC, spirography using bronchodilators, sputum induction, allergy tests, and trial treatment of bronchial asthma are required.
Predominantly nocturnal cough, as well as any history of wheezing and shortness of breath should prompt an examination for asthma.
Reflux-associated cough. The roles of reflux, esophageal dysmotility, and aspiration in cough are controversial. Treatment strategies for those previously supported an aggressive approach to acid suppression and pro-kinetic agents, the evidence base does not support their widespread use. High doses of PPIs can be tested in patients with peptic symptoms and/or signs of reflux (either direct evidence by laryngoscopy or an increased score on the Hull Airway Reflux Questionnaire). Bisphosphonates and calcium channel antagonists can worsen existing reflux disease and increase coughing [7].
Foreign body aspiration. Foreign body aspiration is a common cause of chronic cough among preschool children. During infancy, cough can be due to aspiration of milk or formula, which can be secondary to gastroesophageal reflux, tracheoesophageal fistula, or laryngeal cleft. Toddlers and preschool children can aspirate a small object, such as a food particle, peanut, candy, or small toy. Foreign body aspiration should be considered when there is a sudden onset of unexplained coughing, wheezing, choking, or cyanosis, which then develops into a recurrent/chronic cough.
The possibility of tuberculosis should also be considered. Tuberculosis can cause a chronic cough, especially if there is a secondary infection due to airway obstruction from lymph node protrusions or perforations. In such cases, symptoms may temporarily disappear under the influence of broad-spectrum antibiotics [5].
After a child has had an ARI, parents can be reassured if the cough gradually becomes less severe and dry by the third week, with periods of cough-free time of at least several weeks between episodes and normal examination findings. Further tests are not necessary, especially in a child who is developing well and shows no symptoms during sleep or physical activity at the next checkup [6].
A X-ray can show underlying pneumonia, foreign body, cystic fibrosis, tuberculosis, or bronchiectasis. A film taken during expiration could suggest the presence of a foreign body. Pulmonary function tests should be done if the diagnosis is not obvious. Asthma is diagnosed if airway obstruction is present and if treatment with a bronchodilator reverses the airway obstruction and improves the pulmonary function. Bronchial provocation tests, such as exercises or inhalation of methacholine or histamine, can be useful to identify "hidden asthma" in older children [9].
The doctor should make a balanced choice between a thorough examination of the patient and timely treatment. A thorough examination may lose its meaning due to the natural course of the disease - the time for natural (without medical intervention) recovery will be shorter than the time for a thorough examination. Sometimes, depending on the clinical situation, trial treatment should be preferred, provided that a diagnosis cannot be made at this time for certain reasons.
If a specific cause of cough is established, treatment should be carried out in accordance with the requirements of certain medical and technological documents regulating the provision of medical care for these nosologies [3].
Conclusions. During the initial examination of a child with a cough, it is important to carefully collect anamnesis. If possible, ask for a video of the child coughing, and keep a cough diary to track the conditions under which the cough occurs. Doctors should also consider the benefit-risk of additional tests.
List of references
1. A new look at the treatment of cough in children. YU.V. Marushko. Thematic issue "Pediatrics" №1 (48), March 2019
2. Problems of diagnosis and treatment of respiratory diseases in children: are there any new solutions? Authors: G.V. Beketova, S.M. Nedelskaya, L.V. Besh. 2018
3. Unified clinical protocol of primary health care "Cough in children aged six years and older" 2015
4. Chronic Cough May Mean Underlying Pediatric Illness. Troy Brown, RN; CME Author: Charles P. Vega, MD. 2017
5. Chronic cough in children. J. C. de Jongste, M. D. Shields. Professor dr J. C. de Jongste, Department of Pediatrics, Sophia Children's Hospital, Rotterdam, The Netherlands. 2003
6. Approach to chronic cough in children. Zai Ru Cheng, MMed, MRCPCH, Ying Xian Chua, MMed, MPH, Choon How How, MMed, FCFP, and Yi Hua Tan, MMed, MRCPCH. Singapore Med J. 2021 Oct; 62(10): 513-519.
