Cough in Children

The symptom GPs love to hate because it can appear so trivial. Reassurance and explanation are often all that is required, and this can build a bond with parents and children. Take parents seriously and sympathetically: Nocturnal cough is a destroyer of sleep and family peace.

Published: 2nd August 2022 | Updated: 15th August 2022

Differential diagnosis

Common Diagnoses

  • URTI
  • Bronchiolitis (Usually Aged Under Two)
  • Post-Nasal Drip (e.g. Post URTI, Allergic Rhinitis)
  • Asthma
  • Pneumonia

Occasional Diagnoses

  • Pertussis
  • Recurrent Viral Wheeze
  • Multi-Trigger Wheeze
  • Croup
  • Inhaled Foreign Body
  • GORD
  • Psychogenic

Rare Diagnoses

  • TB
  • Cystic Fibrosis
  • Earwax or Foreign Body in the Ear Canal
  • Immune Deficiency
  • Interstitial Lung Disease
  • Congenital (e.g. Trachea-Oesophageal Fistula)

Ready reckoner

Key distinguishing features of the most common diagnoses

URTIBronchiolitisPN DripAsthmaPneumonia
Child UnwellNoPossibleNoPossibleYes
Chest SignsNoYesNoPossiblePossible
Spring/Summer ExacerbationNoNoPossiblePossibleNo
Marked Nasal CatarrhYesPossibleYesPossibleNo
Cough >3 WeeksNoPossiblePossibleYesPossible

Possible investigations

Likely: None.

Possible: FBC, ESR/CRP, CXR, serial peak flow or spirometry.

Small Print: Pertussis serology, sweat test, secondary care investigations (e.g. for interstitial lung disease or immune deficiency).

  • FBC, ESR/CRP: WCC raised in infection – marked lymphocytosis in pertussis; ESR/CRP elevated in any inflammatory process.
  • CXR: May be helpful in LRTI, TB, inhaled foreign body, cystic fibrosis.
  • Serial peak flow or spirometry: To help confirm a diagnosis of asthma (guidance recommends, in children over the age of 5, testing fractional exhaled nitric oxide in suspected asthma but this may not be practical, or available).
  • Pertussis serology: If a clinical suspicion of pertussis needs confirming.
  • Sweat test: For cystic fibrosis.
  • Other secondary care investigations: May be required after referral (e.g. for interstitial lung disease or immune deficiency).

Top Tips

  • Think pertussis in any paroxysmal cough lasting more than 3 weeks – it is much more common than most people, and many doctors, realise.
  • Educate parents about the likely duration of URTI-related coughs and simple measures to take. Avoid prescribing, as this simply reinforces the tendency to attend the doctor for minor, self-limiting illness.
  • In the asthmatic child, a cough may be a sign of poor control – check treatment, compliance and inhaler technique.
  • Many parents panic that a cough might harm their child. An explanation that a cough is often simply a way of ‘keeping the lungs clear’ can defuse the situation.
  • An aural foreign body is an unusual but remediable cause of childhood cough.
  • Many parents wonder why their pre-school wheezy child has not been given a definitive diagnosis of asthma, particularly after treatment with bronchodilators. It is therefore worth broaching this by explaining the current way wheezy pre-school children are labelled, and why.
  • Psychogenic cough typically does not occur at night.

Red Flags

  • Parents tend to focus on the cough. In the acute situation, rather more important are symptoms and signs of respiratory distress – the NICE traffic light system for febrile children is useful in the acutely coughing febrile child and will help guide the need for admission.
  • A dramatic and abrupt onset of coughing in a child without an URTI should make you consider an inhaled foreign body.
  • Beware the ‘poorly controlled asthmatic’ who isn’t thriving – this could be cystic fibrosis.
  • It can be difficult to distinguish between pneumonia and bronchiolitis in the unwell child. Children with pneumonia will tend to have a high fever and focal crepitations; children with bronchiolitis will be under 2 years old (most common in the first year of life), have a milder fever and more generalised sounds on auscultation. Whatever the diagnosis, if the child is unwell with respiratory distress, it needs admission.
  • In a child with croup, admit if stridor or sternal/intercostal recession at rest, or if agitation or lethargy, pallor or cyanosis, or raised pulse or respiratory rate.
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Website disclaimer

Pulse Reference is based on the best-selling book Symptom Sorter.

The experts behind Pulse Reference are Dr Keith Hopcroft who is the co-author of Symptom Sorter, a GP in Essex and Pulse’s editorial advisor and Dr Poppy Freeman, a GP in Camden and also a clinical advisor to Pulse.

This website is for clinical guidance only and cannot give definitive diagnostic information. Practitioners should work within the limits of their individual professional practice, seek guidance when necessary and refer appropriately.