Signs and symptoms suggesting a specific cause of cough in children (specific cough "pointers")

Specific chronic cough "pointer"	Possible major underlying etiology
History
Pulmonary symptoms
Chronic wet or productive cough*	Suppurative lung diseases (protracted bacterial bronchitis, chronic suppurative lung disease, bronchiectasis), aspiration, abscess, cavitations
Hemoptysis	Infection (eg, tuberculosis), interstitial lung disease, bronchiectasis, autoimmune lung disease
Wheeze (at rest or on exertion)	Asthma (if no other specific cough pointer present other than spirometry, and dyspnea that responds to bronchodilators); bronchiectasis, eosinophilic disorders (if other specific cough pointer[s] present)
Dyspnea (at rest or on exertion)	Asthma or any severe lung disease
Classically recognizable cough sounds^¶	These cough characteristics (eg, barking, honking, whooping) often suggest a specific cause of cough^¶
Recurrent pneumonia	Immunodeficiency, obstructed airways or any conditions causing bronchiectasis
Timing and triggers
Symptoms from neonatal period	Congenital abnormality related to airways, immune function, or causes with predisposition to bronchiectasis (eg, primary ciliary dyskinesia)
Onset after an episode of choking	Inhaled retained foreign body
Cough worsens when child is anxious or attention is focused and is absent during sleep Cough improves with distraction or suggestion and can be voluntarily suppressed	Habit cough (tic cough)
Child has disproportionate thoughts and anxiety about the seriousness of symptoms	Somatic cough disorder (psychogenic cough)
Cough trajectory	Progressive cough (getting worse) warrants further investigation for specific causes A subsiding cough is usually nonspecific and will likely resolve spontaneously A cough that is initially stable (neither progressive nor subsiding) may subsequently follow either of these trajectories
Associated symptoms or conditions
Cardiac disease	Primary cardiac disease causing cough, tracheomalacia or primary ciliary dyskinesia
Neurologic and developmental abnormalities	Aspiration
Feeding difficulties	Laryngeal or trachea disorders, aspiration
Failure to thrive	Any severe lung disease, cystic fibrosis, immunodeficiency, indolent infections (eg, tuberculosis)
Exposure to tuberculosis, pertussis, and/or sick animals and travel history	Tuberculosis and other mycobacterium, pertussis, parasites (eg, Toxocara), and/or zoonoses (eg, trematodes, Strongyloides, Q fever)
History of deep infections±immunodeficiency (primary or secondary to cancer treatment or medications)	Opportunistic infections (eg, fungal)
Autoimmune disease	Interstitial lung disease
Angiotensin-converting enzyme inhibitor use	Known adverse effect of angiotensin-converting enzyme inhibitor
Chronic fever	Indolent infection with or without immunodeficiency
Examination
Digital clubbing	Bronchiectasis or interstitial lung disease
Chest wall abnormality	Any lung disease, neuromuscular disease
Wheezing or crepitations	Any lung disease; in particular, asthma, bronchiolitis obliterans, bronchiectasis (from any cause), bronchopulmonary dysplasia, heart failure, immunodeficiency and aspiration
Hypoxia	Any lung disease
Routine investigations/tests
Abnormal chest radiography	Any lung disease
Abnormal spirometry	Obstructive or restrictive lung/chest wall diseases

* In young children, wet cough is substituted for productive cough.

¶ Classically recognized characteristics are a cough that sounds barking/brassy, honking, paroxysmal/whooping, or staccato or that produces casts. Refer to separate table on classically recognizable cough sounds for details.

Adapted from: Chang AB, Oppenheimer JJ, Weinberger MM, et al. Use of management pathways or algorithms in children with chronic cough: CHEST Guideline and Expert Panel Report. Chest 2017; 151:884.

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Signs and symptoms suggesting a specific cause of cough in children (specific cough "pointers")