As far back as I can remember, my son, Michael, had a recurring cough that just would not quit.
It usually started after he'd caught a cold from his big sister. But often we couldn't pin it to anything. Neither could his doctors -- and we saw many in our years-long quest to find relief from The Cough. At night, he'd cough so hard that he'd wake up and often vomit in bed. We tried everything: over-the-counter and prescription antihistamines and cough syrups, antibiotics, inhalers and nebulizers. When allergy tests determined that Michael was allergic to dust mites, we bought special casings for his pillow and mattress, replaced curtains with a shade, and tried to convince him to put away his menagerie of stuffed animals (which he adamantly refused to do). I even subjected the poor kid to an endoscopy, during which doctors slid a thin flexible tube down his throat while he was under anesthesia. In the end, we never did get a definitive diagnosis, and The Cough mysteriously faded away when he was about 13.
Not all coughs are as tough to figure out as my son's was. Chronic cough is typically defined as one that lasts more than four weeks. "It's the single most common reason that parents call my office for a new-patient evaluation," says Ray S. Davis, M.D., professor of clinical pediatrics in the division of allergy immunology and pulmonary medicine at Washington University School of Medicine, in St. Louis. But decoding a cough is not a matter of, say, equating a dry, hacking cough to one cause and a wet, loose cough to another, he explains. It's also important to know that a cough is a symptom, not a disease.
I wanted to write this story because I know how eager parents are to get to the bottom of their child's chronic cough. And with the terrifying enterovirus D68 on the scene -- of which cough is a main symptom -- it's even more crucial to understand what's going on. These are the questions you should ask yourself, and what I wish I'd learned sooner.
Could it just be a cold?
Probably. The most common cause of cough in kids is an upper-respiratory infection from one of more than 100 cold viruses. Your child may have a mild fever from the virus and develop a cough, explains William Berger, M.D., clinical professor in the department of pediatrics at the University of California, Irvine, and a Parents advisor. "Children typically get about eight to ten colds a year and most last five to seven days,'' Dr. Berger adds, though the cough may last much longer than the runny nose. "Since kids are constantly swapping germs, it may seem like the same cold and cough is going on forever, when it's more likely that your child has a new cold and cough, back to back." As congestion builds and mucus drips down the throat, some kids can't cough it out. So they swallow it. All that mucus can also upset a child's stomach or trigger the gag reflex, which can cause her to throw up.
What to do If your child has trouble breathing or her symptoms get worse, contact your doctor, who may have her tested for enterovirus D68. In most cases though, a cold needs to run its course. Besides general TLC, give your child lots of fluids: water, warm decaf tea, even an ice pop all help. Stay away from carbonated drinks or citrus juice, which can irritate the throat. And avoid multi-symptom cold and cough preparations; if you combine them with other medicines, it may increase the risk of overdose from overlapping ingredients. (Keep in mind that the American Academy of Pediatrics does not recommend cough and cold medications for kids under 6.) Try a cool-mist humidifier or vaporizer at night; use saline nasal spray or a suction syringe to clear nasal congestion. For children over 1 year only, offer 1/2 to 1 teaspoon of honey in tea or on toast as needed to help loosen the cough. "Parents often worry when a cough is persistent, especially when it sounds harsh," explains Carrie Quinn, M.D., a pediatrician at the Kravis Children's Hospital at Mount Sinai, in New York City. "But there are questions you should ask to determine how serious the cough is. Is he playing normally or is he lethargic? How is he eating?" See a doctor if the cough is lingering after two to three weeks, or if your child experiences breathing difficulties, vomiting, or a spike in fever.
Could it be sinusitis?
If a cough lasts more than ten days and shows no signs of getting better, and your child's nasal discharge is thick and yellowish-green, he may have sinusitis, an inflammation of the mucus lining of the nose and sinuses. It creates pockets of air along the brow, the cheekbones, and the nose; as congestion builds, sinuses become a breeding ground for bacteria. In addition to a chronic cough, kids may have postnasal drip, bad breath, low energy, and puffiness and dark circles around the eyes. Older children may complain of headache. Even a low-grade sinus infection can cause a never-ending cough.
What to do Your primary-care doctor may prescribe an antibiotic to zap the infection and nasal sprays to ease symptoms. If, after a few days, your child seems no better, she may need another round of antibiotics or a different medication. Acetaminophen, ibuprofen, and/or warm compresses can help with headaches or facial pain. Your doctor may refer you to an otolaryngologist, who can examine your child's ears, nose, and throat with special instruments to see what's going on. He'll also be able to notice any structural issues, such as a deviated septum, that can make a child more susceptible to sinus problems.
Could it be an allergy?
Yes, if the cough is accompanied by a drippy nose and itchy eyes, or if it arrives around the same time every year or after each visit to Grandma and her two dogs. Allergy is simply the body's overreaction to a substance (allergen) that's usually harmless to most people. Allergens trigger the release of histamine and other biochemical substances, which cause inflammation and congestion, chronic postnasal drip, and cough. Allergic rhinitis can be seasonal (possibly caused by pollen from trees, weeds, grasses, and outdoor molds) or perennial (from year-round indoor allergens such as pets, dust mites, and indoor molds).
What to do Saline nasal spray or an over-the-counter antihistamine may help dry up nasal secretions. If that doesn't work after a day or two, your doctor may prescribe corticosteroid or antihistamine nasal sprays. Stay away from OTC decongestants and cough medicines: Although persistent cough can be a hallmark of nasal allergies, experts say there is no proof that the meds are effective in relieving a cough and may sometimes make symptoms worse.
If you suspect seasonal allergies are the trigger, try to keep your child inside during morning hours when pollen counts are highest. To combat a dust-mite allergy, there are several things you can try to allergy-proof your home -- especially your child's bedroom. Encase his pillow (which should be polyester/fiberfill, not down feathers) as well as mattress in dust-mite-proof covers, wash bed linens weekly, and wash stuffed animals often. Instead of a fan, run an air conditioner as well as a dehumidifier to prevent mold (clean the filters regularly!). And don't smoke. Even if you smoke outside your home, the fumes stay on your clothes and will irritate a cough. Ditto for electronic cigarettes or "vape" pens.
If none of these remedies work, you should see an allergist/immunologist for a kid-friendly scratch test to determine precisely what's triggering the cough and decide on a treatment plan. Left untreated, nasal allergies can lead to chronic sinusitis, ear infections, sleep disorders, and asthma, and may affect speech and language development as well. If your child is older than 5 and has not responded to traditional therapies, the next best option may be immunotherapy -- a course of shots (for up to several years, depending on how well your child responds) that slowly bolsters the immune system's ability to fend off allergy symptoms.
Could it be asthma?
Asthma is a respiratory condition affecting the tiny airways in the lungs. It's been the most common chronic disease in children for decades and symptoms can be triggered by an upper-respiratory infection, inhaled allergens, irritants such as secondhand smoke, cold and dry air, exercise, even a temper tantrum. Your child may wheeze or have shortness of breath, a tight feeling in his chest, or a cough. However, not every child with asthma wheezes. Many only have a chronic cough, which doctors typically refer to as cough-variant asthma. This can go unrecognized for years because standard diagnostic tests that measure lung capacity may turn out normal or the child may be too young (under 6) to properly perform the breathing test. "If a mother tells me her child gets one cold after another that settles in his chest and leads to recurrent bouts of croup or bronchitis, often the underlying cause of all that misery is cough-variant asthma," says Dr. Davis.
What to do Your doctor will ask for a history of your child's symptoms (eczema and recurrent ear infections as a baby are clues) as well as your family's medical history. If your child is old enough, the doctor may perform pulmonary-function tests to make sure his lungs are healthy. Pay attention to what sets off the cough: Does allergy season do it? Is he out of breath barely five minutes into his soccer game? Does he wake up coughing in the middle the night? Taken together, all of these signs make a doctor suspicious of asthma.
Whether it's classic asthma or cough-variant, it usually responds to the same treatments: bronchodilator and/or anti-inflammatory meds. One is a "rescue" medication for the moment an attack (or coughing fit) begins, and the other is a daily "controller" medication to keep the disease under control.
Could it be whooping cough?
Pertussis is a highly contagious bacterial illness of the airways and lungs that often starts with cold-like symptoms (runny nose, sneezing) followed by short bursts of uncontrollable coughing that sometimes end with an unmistakable whoop. Children may throw up and turn blue as they struggle for air. "It's often known as the 100-day cough," says Dr. Berger, whose home state of California has declared a pertussis epidemic in the past year.
What to do Call the doctor ASAP. Your child needs antibiotics. They're most effective when given in the first seven days of infection -- but can also be given to other family members at a later point to prevent the disease from spreading. Older children and adults with pertussis may have only a mild cough, but pertussis can cause life-threatening complications in babies who are too young to be vaccinated or haven't had all four doses of DTaP (a vaccine that also protects against tetanus and diphtheria). Adults who work closely with infants should get Tdap, the whooping cough booster, and pregnant women must get Tdap between the 27th and 36th weeks of each pregnancy, even if they got the shot before they became pregnant.
Could it be GERD?
When acid from the stomach backs up into a child's throat due to weak esophageal or stomach muscles, the result can be GERD (gastroesophageal reflux disease), which many people think is only an adult disorder. Babies can't tell you they have heartburn, but if they spit up, gag, or are very fussy during feedings, this may be why. Older kids may wheeze and cough especially at night when they're lying down, or complain of pain in the chest or throat. GERD is usually diagnosed based on a history of symptoms and trial-and-error lifestyle changes, but it may require a consultation with a pediatric gastroenterologist.
What to do Those lifestyle changes are often enough. Keep babies upright for 30 minutes after feeding and elevate the head of a child's mattress while she sleeps to minimize coughing. For older kids, cut back on foods that typically set off symptoms of GERD, such as citrus fruits, tomatoes, chocolate, peppermint, and anything spicy. Keep a record of what your child eats to see whether there's a correlation. Try not to feed older kids right before they go to bed and cut back on foods known to trigger the condition.
Could it be a tic or "habit cough"?
This cough is particularly difficult to diagnose and treat. It's usually mentioned after all other reasonable diagnoses have been excluded. Your child may have had a cold or flu that left her with a telltale cough. Even though the cold is gone, the cough isn't -- except when she's sleeping. "Your child probably isn't doing this on purpose," says Dr. Berger. "She may tell you she feels a tickle in her throat, or not even realize she's coughing." Sometimes, the tic is anxiety-driven and can become habitual. In other cases, kids just get in the habit of coughing to clear their throat. If they get attention for it, they keep it up.
What to do Simply reassuring a child that she's no longer sick might be enough. (You may need to get your doctor to say this.) However, the act of coughing itself can irritate the throat and lead to a cycle of more coughing. To break it, offer a sip of water, a lollipop, or, for older kids, a cough drop to help suppress the urge to cough. Praise and positive reinforcement when she does resist coughing may help. Some pediatric pulmonologists teach relaxation therapy to control tics. If nothing works, consult a child therapist to see if an underlying issue -- perhaps a school phobia, shyness, bullying -- is bothering her.
Where to Go for Help
Your Primary-Care Physician is your first stop for diagnosing and treating most coughs. She'll recommend a trial of OTC and Rx medications. If she can't, she'll refer you to ...
An Allergist. She can administer skin tests to pinpoint what your child is allergic to. Still inconclusive? The doctor may order a chest X-ray or lung-function test to measure the pattern of airflow in and out of the lungs, or refer you to a pulmonologist for a closer look at the lungs. She may also suggest you
An Otolaryngologist (ENT). After taking a detailed history, the ear, nose, and throat specialist will examine your child's nose and sinus cavities. He may need to surgically correct chronically infected tonsils, adenoids, or sinuses.
Originally published in the December 2014 issue of Parents magazine.
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