• Asthma manifests most often as difficulty in breathing arising from mucosal oedema and bronchospasm. The diagnosis is easy in such cases.
• Cough is another manifestation of bronchial hyperreactivity in asthma.
• The patients typically have cough during the night, during exercise, and in cold weather.
• It is important to evaluate the child's condition clinically on several occasions: What are the child's symptoms, how does expiration appear and sound (if the child is old enough, always auscultate forced expiration).
• All symptoms or their absence are recorded.
• In children above 5 years of age, a 1- to 2-week follow-up of peak expiratory flow (PEF) values with a simple instrument at home is a useful examination.
• A bronchodilatation test or a free exercise test can also be performed.
• Asthma should be suspected if
  • Wheezing is heard repeatedly on auscultation of expiration.
  • PEF values are lower than gender- and height-adjusted reference values.
  • PEF values are paroxysmally reduced by 20%.
  • PEF values decrease by 15% under exertion and increase by at least 15% after the inhalation of a sympathomimetic drug. For calculation see program for calculating PEF on the Finnish Medical Society Duodecim Web site.
• The frequency of symptoms and the circumstances in which they appear as well as the efficacy of a possible trial medication can be followed up by using a symptom diary.
• In small children a trial medication with inhaled corticosteroids is often the only possibility (König, 1981). Education for the proper administration of the inhaled medicine must be arranged.

A Foreign Body in the Respiratory Tract

• The patient may have had symptoms for weeks or months, without a foreign body being suspected.
• When taking the history of a coughing patient it is always worthwhile to ask specifically for the possibility of a foreign body.
• If the foreign body is radio-opaque (which is rare) the diagnosis can be made by chest radiograph. In other cases a bronchoscopy is indicated (Puhakka et al., 1989).

Other Causes of Cough

• Children subjected to cigarette smoke at home may suffer from continuous cough.
• Gastro-oesophageal reflux may associate with prolonged cough. The history may reveal a considerable tendency for rumination in infancy (Puhakka et al., 1989). The child should be examined in specialist care by using pH registration and, if necessary, endoscopy.
• Typical manifestations of psychogenic cough include hawking, speaking with a loud voice and coughing in specific situations. In 10% of children with prolonged cough the condition is psychogenic.

Related Evidence

• Nedocromil sodium prevents exercise-induced bronchoconstriction (Spooner, Saunders, & Rowe, 2002) [A].
• There is currently no evidence to support the use of inhaled anticholinergic medications in the management of prolonged nonspecific cough in children (Chang, McKean, & Morris, 2004) [D].

Definitions:

Levels of Evidence

1. Strong research-based evidence. Multiple relevant, high-quality scientific studies with homogeneous results.
2. Moderate research-based evidence. At least one relevant, high-quality study or multiple adequate studies.
3. Limited research-based evidence. At least one adequate scientific study.
4. No research-based evidence. Expert panel evaluation of other information.

References open in a new window

This guideline is included in "EBM Guidelines. Evidence-Based Medicine" available from Duodecim Medical Publications, Ltd, PO Box 713, 00101 Helsinki, Finland; e-mail: info@ebm-guidelines.com; Web site: www.ebm-guidelines.com.

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