Problems in Family Practice

problems in Family Practice Coughing in Childhood Hyman Sh ran d , M D Cambridge, M assachusetts Coughing in childhood is a common complaint involving a wide spectrum of underlying causes which require a thorough and rational approach by the physician. Most children who cough have relatively simple self-limiting viral infections, but some may have serious disease. A dry environment, allergic factors, cystic fibrosis, and other major illnesses must always be excluded. A simple clinical approach, and the sensible use of appropriate investigations, is most likely to succeed in finding the cause, which can allow precise management. The cough reflex as part of the defense mechanism of the respiratory tract is initiated by mucosal changes, secretions or foreign material in the pharynx, larynx, tracheobronchial Table 1. Persistent Cough — Causes in Childhood* tree, pleura, or ear. Acting as the “watchdog of the lungs,” the “good” cough prevents harmful agents from Common Uncommon Rare entering the respiratory tract; it also helps bring up irritant material from Environmental Overheating with low humidity the airway. The “bad” cough, on the Allergens other hand, serves no useful purpose Pollution Tobacco smoke and, if persistent, causes fatigue, keeps Upper Respiratory Tract the child (and parents) awake, inter Recurrent viral URI Pertussis Laryngeal stridor feres with feeding, and induces vomit Rhinitis, Pharyngitis Echo 12 Vocal cord palsy Allergic rhinitis Nasal polyp Vascular ring ing. It is best suppressed. Coughs and Prolonged use of nose drops Wax in ear colds constitute almost three quarters Sinusitis of all illness in young children. The Lower Respiratory Tract Asthma Cystic fibrosis Rt. middle lobe syndrome purpose of this article is to outline a Viral pneumonia Tuberculosis Diaphragm hernia rational approach to this common Mycoplasma Atypical mycobacteria T. E. fistula Aspiration Foreign body Sequestration of lung problem which will allow effective Bronchiectasis Congenital cyst Lung abscess Mediastinal mass therapy based on specific diagnosis. Hemosiderosis By far the majority of children with Histoplasmosis Fungal infection cough as their presenting symptom Pleural involvement have an acute self-limiting viral upper Parasi tes Pneumocystis carinii respiratory tract infection. Sometimes Visceral larva migrams - although rarely — the cough may be Cardiovascular Disease Congestive failure a. ) Congenital heart disease an indicator of serious disease. The b . ) Rheumatic fever cough may be caused by congenital Psychogenic malformations, inherited deficiencies, Cough tic infections, allergies, neoplasms, Newborn Fistula trauma, or irritant substances in the air Vascular ring (Table 1). *Coughing lasting more than a few weeks From the Division of Pediatrics and Adoles Uncomm on causes in Boston may be common in other parts o f the w orld. cent M e dicine, M o u n t A u b u r n H o s p ita l, Cambridge, Massachusetts. Requests for reprints should be addressed to Dr. Hyman . rand- Division of Pediatrics and aolescent Medicine, Mount Auburn ospital, 330 M ount Auburn St, Cambridge, Mass 02138. THE JOURNAL OF FAM ILY PRACTICE, VOL. 2, NO. 1, 1975 5 5 The family physician must recog unnecessary investigations and opera syncytial or parainfluenza) account for nize those children suffering from the tive procedures when a carefully-taken most of the lower respiratory tract simple common causes while remain history could have suggested the diag infections in infants and children seer ing alert for the small minority who nosis. A family history of cystic in urban pediatric practice.1 Starting might have a serious problem. Experi fibrosis, tuberculosis, allergic prob usually as a viral URI, they present ence will dictate which children need lems, or immunoglobulin deficiencies either as cases of “pneumonia” 0r further investigations, antibiotics, or has obvious implications. bronchiolitis. These children are not surgery, and which are best managed Although caused by a wide variety likely to benefit from antibiotics. by simple symptomatic relief and a of viruses, the common upper respira Coughing in the newborn is so “wait and see” policy. The more tory tract infection (URI) is readily uncommon that its presence, particu common causes are easily recognized recognized by the usual coryza, febrile larly during feeding, is highly sugges in the office; uncommon causes may malaise, and cough which is usually tive of tracheoesophageal fistula. If the need the skills of a specialist in respira worse at night and no doubt prevents a cough is worse at night it could be tory disease. postnasal drip from entering the caused by a postnasal drip induced by larynx. A family history or seasonal the coryza of a URI, bedroom allergy, History “epidemic” is often found. A child sinusitis, or dried out air in an who has had a “cold” and cries a great overheated room. A child who snores A good history can provide valuable deal has probably developed an acute at night, sleeps with an opened mouth, clues (Table 2). All too frequently the otitis media. A feverish child with and has had repeated ear infections coughing child has been given a poly- grunting painful cough, rapid breath may be suffering from adenoid pharmaceutic cough syrup containing ing, and active alae nasae is most likely enlargement or allergic rhinitis. Chil obsolete medications which may delay to suffer from bacterial pneumonia, dren put to bed with a bottle of milk the identification of serious disease. although nowadays this is seen infre are prone to both cough and middle Other children have been subjected to quently. Viral infections (respiratory ear infections. If a child appears reasonably well but is constantly coughing, perhaps with wheezing and Table 2. Suggestive Clues in History sneezing, the cause may be asthma. Asthma should also be suspected wherever there is a history of eczema. Clue Probable Cause If the child looks sickly, fails to thrive, and has foul loose stools, the most 1. Newborn period T. E. fistula (especially if associated likely diagnosis is cystic fibrosis. A with feeding) persistent cough after an exanthem or Cystic fibrosis Vascular ring viral URI may be due to a complicat 2. Onset with febrile coryza Viral URI ing viral pneumonitis (rarely Viral pneumonitis Mycoplasma mycoplasma) or may reflect segmental 3. Postoperative Atelectasis collapse and bronchiectasis. Any previ Lung abscess ous history of gagging is highly suspi 4. S tory o f gagging Foreign body cious of an aspirated foreign body. A 5. Seasonal a.) W inter M ould allergy history of recurrent lung infections Recurrent URI should bring to mind asthma, cystic b. Summer Pollen and grass allergy fibrosis, atrial septal defect, collapsed 6. More at night Postnasal drip with mouth breathing Low humidity segment of lung, or an immuno Allergens in bedroom (feathers, dust, stuffed toys) globulin deficiency. A URI with much Adenoid enlargement coughing is usually viral. A strepto 7. Eczema Asthma coccal pharyngitis starts with a fever 8. Wheezing Asthma and a sore throat which is worse on Foreign body (especially if localized) Cystic fibrosis swallowing; it may have a frequent 9. Bad breath Rhinitis short cough. In the infant, strepto Adenoiditis Nasal foreign body coccal rhinitis is not uncommon and Sinusitis often causes excoriation beneath the 10. Sputum Bronchiectasis nares. 11. Foul stools and underweight Cystic fibrosis Enormously enlarged tonsils and 12. Shortness of breath Asthma Congestive heart failure adenoids can obstruct the airway and Diffuse lung disease cause progressive hypoxia, reactive 13. Worms in stool Ascariasis pulmonary hypertension, and chronic 14. Puppy in the house and pica Visceral larva migrans cor pulmonale.2 Children with this 15. Fever and sweating Lung infection condition snore noisily at night, have 16. Pain in chest Pleural involvement chronic respiratory problems, and 17. Child in kindergarten Recurrent viral infections 18. Wiping nose upwards (Allergic Salute) Allergy develop congestive failure with or 19. W iping nose beneath nares Streptococcal rhinitis without cyanotic spells and coma. 20. V isit to a cave (bats) Histoplasmosis Emergency treatment requires the provision of an adequate airway and 56 THE JOURNAL OF FAM ILY PRACTICE, VOL. 2, NO. 1, 1975 management of the congestive failure. mucopus after emesis. Thus, we can the red engorged mucosa of infection. Subsequent rem oval of tonsils and not speak of productive (“wet”) or Nasal polyps are often found in chil adenoids gives dram atic relief. nonproductive (“dry”) coughs. How dren with cystic fibrosis. A purulent, Children whose mothers smoke ever, the older child with a loose, blood-stained nasal discharge indicates have a higher incidence of bronchitis rattling cough and purulent sputum presence of a foreign body. Sinusitis is and pneumonia.3 Many adolescents may well have bronchiectasis with or a common complication of UR1 and already have a smoker s cough. without underlying cystic fibrosis. may be the cause of recurrent ear and A child coughing after anesthesia Hemoptysis is a most alarming lung infection. may well have aspirated material into symptom which has many serious Inspection of the chest may reveal the lungs producing an area of col causes (Table 3). A child bleeding the pigeon chest of chronic asthma or lapse, with or without abscess. from the nose may appear to cough up a differential in the movement of the Some coughs have diagnostic blood. chest wall during respiration

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