If you have more than one child, you know that all coughs are not created equal. Some kids cough so loud and hard that you’re fairly sure part of their lungs will come up, whereas others seem like they need a firm pat on the back–and there’s everything in between. In my practice, I often need to handle a situation in which a child has a very loose cough that keeps getting worse. Here is my cough classification scheme that might provide some insight the next time you find yourself hearing a cough from your child’s room late at night.
The croupy cough always gets my attention.
These are the kids who sound like seals barking at the National Aquarium. It’s such a distinctive sound that once you hear it, you’ll never forget it. Hearing a croupy cough always makes me nervous because croup can potentially cause respiratory distress and compromise, and when it’s accompanied by noisy breathing called stridor, can be a true emergency requiring supplemental oxygen, breathing treatments, and even hospitalization. However, in many cases, a croupy cough can be simply managed by cool, humid air, either from sitting in a steamy bathroom, spending some time breathing the outdoor air, or breathing the cold air standing in front of an open freezer. Croup is a viral infection, so if symptoms are not causing respiratory distress, time and supportive care are the prescriptions in order.
A “tight” cough can also be confusing to figure out.
A tight cough is typically not productive of any mucus and doesn’t “rumble” in the chest. It almost sounds like a “wheezy” cough, and that’s because this cough is often associated with asthma or similar conditions that cause wheezing, like bronchiolitis, a viral infection of the lower, smaller diameter airways. For children with asthma, sometimes that tight cough is all I hear, and they need treatment with aerosolized bronchodilators and oral anti-inflammatory steroid medicines to help their breathing. These medicines don’t help most children with viral bronchiolitis; these kids just need time and supportive care to recover, but some do require supplemental oxygen and hydration support.
When I hear a tight cough, I can get some more information from listening to the lungs. If there is wheezing on my exam but only heard on one side in one lung field and the patient is a younger child, I get concerned about an aspirated foreign body into the lungs. An inhaled piece of popcorn or even a small bead or toy part can obstruct a segment of the airway and cause focal, isolated wheezing. An X-ray with 2 views, with the child lying on one side and then the other, can help increase or decrease the likelihood of this situation. If suspicion for aspirated foreign body is high, then the child needs a study called a bronchoscopy in the operating room, where a scope is introduced into the bronchus in the lung to look for a possible object that is stuck there. If an object is found, it will be removed.
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Parents can have a difficult time dealing with the loose cough.
This one is a little trickier to decipher, for myself included. A loose cough often means that it is also productive, which of course opens up the can of worms of, “What color is the mucus?” While green/yellow mucus doesn’t always indicate pneumonia, when there’s a loose cough I want to make absolutely sure pneumonia isn’t happening–especially in the presence of fever. But just as often as not, fever and a loose, junky cough that echoes throughout the tri-state area can be caused by a viral upper respiratory infection as well as pneumonia. A lung exam can help differentiate between the two. When there are crackly noises heard through the stethoscope, especially when they are on one side and don’t go away with coughing, then I lean more towards pneumonia as opposed to a viral URI. Clear lungs are reassuring regardless of the sound of the cough. The bottom line is that a loose cough does not automatically mean that a child has pneumonia.
Here's when your child should see a doctor.
A toxic-appearing child who is working so hard to breathe that she can’t adequately oxygenate or hydrate, or a cough that seemed to get better and then get worse, or any extra sounds while breathing at rest are all reasons for concern. Beyond that, understand that there are different types of cough and that, when considered in isolation, they aren’t always perfectly diagnostic–but the differences can help sort out the underlying cause, to a certain degree.
My advice? Pay attention to the cough nuances but don’t always hook your star to a specific diagnosis if that cough sounds rattle-y and kind of loose. Just make sure you get it checked out.
Main Image: Dr. Christina Johns. Courtesy PM Pediatrics
