It’s the time of year when many children seen by nurses will be coughing, spluttering and wheezing.
Coughs are common for children, particularly preschoolers, and the vast majority are caused by colds and other viral upper respiratory tract infections (URTI) and will improve with rest and time.
Child Health nurse practitioner Debbie Rickard says while once viral coughs and colds used to be very seasonal in recent years, it has become more common for them to pop up at any time, including summer.
When children do present with a runny nose or other symptoms indicating their cough is likely acute and viral, parents should be reassured that a cough is a normal reflex. They should be given a plan for looking after the child, including the likely trajectory of the cough (many children can cough for up to three weeks or more) and clear advice on when to seek medical attention if the symptoms worsen or the child is not improving (particularly an infant not feeding or sleeping and is lethargic) or the cough continues for longer than four weeks.
Parents worried and sleep-deprived by their child’s cough should also be advised that over-the-counter cough medicines can cause serious side effects in young children and should not be given to children under six.
Seasonal viruses can trigger asthma, but Rickard says it is common for a young child to respond to a winter virus with an asthma-like cough or wheeze that responds to inhalers; however, they may outgrow this and not have asthma.
When a child presents with a distressing cough where the cause is less clear, or becomes recurrent, a more extensive history should be taken, including whether its onset was sudden (possibly the child inhaled a foreign body) and the nature of the child’s cough (wet/dry/how long going on/do they cough at night/triggers).
Checking immunisation status and environmental factors (like damp living conditions and cigarette smoke exposure) is also helpful in the initial assessment of a child with an acute cough. Rickard says parents think if they smoke outside the house it will have less effect on their children, but it still has an effect if the smoker is in regular close contact or is the main carer who cuddles the child.
A clinical assessment will usually include checking the child’s respiratory and heart rate, temperature, ear/nose/throat exam, a chest examination and checking the child’s demeanour, such as if child is comfortable, happy, distressed or lethargic.
Red flags to watch out for include signs of respiratory distress like nasal flaring, a tracheal ‘tug’ at the front of the neck and obstructed breathing causing harsh stridor noises.
Age is also an important consideration with, for example, croup’s barking cough (a cough like a seal caused by a virus triggering inflammation and narrowing of the larynx and windpipe) being rare in children over six. For example, an eight-year-old who arrived at Rickard’s clinic had an initial ED diagnosis of croup but was later found to have whooping cough.
Also in very young children wet cough symptoms may be different as they don’t cough regularly or frequently. So rather than coughing up mucous, they swallow it and eventually throw up, therefore it can be useful to check whether the child has vomited and reassure parents this is normal for infants.
Bronchiolitis is a very common viral chest infection in babies, affecting one in three before the age of 12 months, and is the most common cause of wheezing in children under a year. It is usually mild, but if a baby is under three months old or has a severe case they may need to be admitted to hospital.
If a child has a consistent, wet/moist, productive cough for more than four weeks then they need to be reviewed as they may have a bacterial infection that needs antibiotics. Rickard says sometimes it may be that the child has recovered from one virus just to catch another straight afterwards, with children in childcare or preschools on average having 15 illnesses a year.
If symptoms and a chest examination indicates an infection needing antibiotics, it is important to explain to the family why taking the full course of antibiotics is essential – particularly if the child has had frequent respiratory infections.
New Zealand, unlike most other developed countries, still has problems with bronchiectasis – especially in Māori and Pacific children living in areas of socioeconomic deprivation. Leaving a wet, persistent cough untreated increases the risk of bronchiectasis, leading to scarring and permanent damage to the lungs.
Coughs in children resources:
- Asthma and Respiratory Foundation NZ child and adolescent asthma guidelines: a quick reference guide (2017): www.asthmafoundation.org.nz/resources/child-and-adolescent-asthma-guidelines
- Cough in Children, Health Navigator: www.healthnavigator.org.nz/health-a-z/c/cough-in-children
- Cough in Children, BPAC 2010: https://bpac.org.nz/BPJ/2010/July/cough.aspx
- Nurses can also access their regional ‘HealthPathways’ via their local DHB or PHO