Causes of chronic cough in children

Primary cause	Typical age of presentation^*	Risk factors or mechanisms	Major evaluation method (in addition to clinical findings)
Pulmonary causes
Aspiration^¶ (recurrent small volume)	Children with neuromuscular disorders: Can present at any age Those with progressive disorders: Prevalence increases with age Those with airway abnormalities (laryngeal cleft, H-fistula): More likely to be symptomatic from birth	Primary swallowing dysfunction Laryngeal disorders (eg, laryngeal cleft, tracheoesophageal fistula) Achalasia	Swallowing assessment (eg, videofluoroscopic) and other evaluation as indicated^Δ
Asthma, cough-dominant asthma^¶	Early childhood through adolescence	Genetics, environment, atopy, postacute respiratory infections	Spirometry, F_eNO, airway hyperresponsiveness
Chronic endobronchial suppurative disease^¶ (protracted bacterial bronchitis, chronic suppurative lung disease, bronchiectasis)	Protracted bacterial bronchitis is more common in children aged <5 years but can occur at any age Bronchiectasis can occur at any age	Cystic fibrosis^¶ Immunodeficiency (primary or secondary) Primary ciliary dyskinesia^¶ Aspiration Postinfection (eg, tuberculosis, pneumonia, etc)	Sweat test, genetic screening Evaluation of immune function Cilia biopsy, genetic testing Chest CT, bronchoscopy Refer to "Aspiration" above
Chronic pneumonia^¶	Early childhood through adolescence	Chronic atelectasis, mucous plugging, plastic bronchitis Pathogens include tuberculosis, nontuberculosis mycobacteria, mycoplasma, fungi, and chlamydia	Chest CT, bronchoscopy Relevant microbial assessment (eg, QuantiFERON gold and Gene Xpert for tuberculosis)
Eosinophilic lung disease^¶	Late childhood through adolescence	Primary or secondary (ie, related to parasitic disease)	Bloods and bronchoalveolar lavage
Inhaled retained foreign body^¶	Infancy and early childhood	Young child, history of choking (even if days or weeks before cough onset)	Bronchoscopy
Interstitial lung disease^¶	Any age	Primary genetic abnormality, post-severe infection bronchiolitis obliterans, autoimmune disease, radiation, drugs	Relevant genetic or autoimmune test (with or without lung biopsy), chest CT
Mechanical inefficiency	Infancy through early childhood	Tracheobronchomalacia and other airway anomalies Vascular rings or other anomalies that cause tracheal narrowing	Dynamic bronchoscopy Chest CT with contrast Chest MRI (if vascular cause suspected)
Noninfective bronchitis^¶	Secondhand exposure: Any Primary exposure: Adolescence	Exposure to environmental pollutants (eg, tobacco smoke, vaping/inhalation of toxins, traffic pollutants, fungi, occupational)	History and removal of trigger
Postinfection (self-resolving)	Early childhood through adolescence	Viral infections, pertussis, parapertussis	PCR and/or serology
Space-occupying lesions^¶	Any age	Cysts and tumors	Chest CT or MRI scan
Extrapulmonary causes
Causal role likely
Cardiac^¶	Infants	May cause cough due to airway compression, pulmonary edema, or arrhythmia	ECG and other evaluation as indicated
Ear disease^¶	Early childhood	Oto-respiratory reflex (Arnold reflex), in which stimulation of the auricular branch of the vagus nerve triggers cough	Examination of the ear canal and removal of the object, or treatment of disease that is triggering the cough
Tic cough (habit cough) or somatic cough disorder (psychogenic cough)^¶	Childhood through adolescence	May be isolated, but more likely if other tics are present Some children have generalized anxiety or disproportionate anxiety about the seriousness of their symptoms	Suppressibility, distractibility, suggestibility, variability, and presence of a premonitory sensation; cough absent during sleep Response to behavioral therapy (eg, suggestion therapy)^◊ Children with somatic cough disorder may require referral to a psychologist and/or psychiatrist if unresponsive to suggestion therapy
Medications^¶	Any age	ACE inhibitors (common), any inhaled medication, proton pump inhibitors, other drugs (uncommon) Certain other medications (eg, cytotoxic drugs) may be associated with interstitial lung disease	Discontinuation of medication Evaluation for interstitial lung disease (eg, HRCT)
Causal role unlikely
Esophageal disorders	Any age	Gastroesophageal reflux (acid and nonacid) and eosinophilic esophagitis	Esophageal pH monitoring or impedance monitoring, with or without endoscopy
Upper airway pathology	Any age	Chronic sinusitis, obstructive sleep disorders^§	Evaluation guided by suspected disorder (CT, polysomnography)

ACE: angiotensin-converting enzyme; CT: computed tomography; ECG: echocardiogram; F_eNO: fractional exhaled nitric oxide; HRCT: high-resolution computed tomography; MRI: magnetic resonance imaging; PCR: polymerase chain reaction.

* Age groups are only a guide and are not comprehensive.

¶ Children with these disorders typically have specific signs and symptoms that are clues to the underlying disease, sometimes known as specific cough "pointers."

Δ Evaluation for suspected aspiration may include bronchoscopy, esophageal pH monitoring or impedance monitoring, endoscopy, or nuclear medicine scans. Refer to UpToDate topic on evaluation of children with suspected swallowing dysfunction.

◊ Refer to UpToDate table on suggestion therapy for habit cough.

§ Possibly related to aspiration of secretions rather than primary pathology.

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Causes of chronic cough in children