CHILD WITH A COUGH THAT DOES NOT GO

A cough that does not go

That cough that lasts over time is a frequent problem, especially in winter and is a frequent reason for use all'allergologo. The persistent cough is a cough that lasts for more than 15 days, chronic cough is one that persists beyond three to four weeks. Very often these children are subjected to radiographic, laboratory examination, multiple therapies. In fact, in most cases the problem can be resolved without the need for investigation only on the basis of clinical data and history of cough.

It 's always allergy?
Asthma, namely the so-called persistent cough-equivalent asthma is the most common cause of cough that does not end within those time limits in which usually runs out of cough due to normal infections of the upper respiratory tract. It is possible, however, other conditions, independent by allergy, which may happen with this symptom which, taken together, represent the major cause of the problem. In daily practice, on the contrary, there is a deep-rooted tendency to almost always "allergic" cough that does not resolve to enter the usual limits, and that does not respond to the usual therapies, and appear to be very undervalued, even today, diseases such as rhinosinusitis that in reality it is very common and is responsible for the symptom "persistent cough" to an almost equal footing with asthma.

What are the most common causes?
After asthma, the most common cause of persistent cough-consecutive chronic infections of the upper respiratory tract. It 'a situation that can occur frequently in small kindergarten children who can easily contract a viral infection while the second has not yet disappeared cough caused by an initial infection.
Other causes may be sinusitis or rhinosinusitis, the bronchopneumonia, infections of germs particular, so-called atypical bacteria (Mycoplasma and Chlamydia), whooping cough, psychological reasons (psychogenic cough). Less frequent so-called aspiration syndromes, ie the penetration of foreign material into the respiratory tract, food or otherwise, as may occur by accident (inhalation of foreign body) and in patients with gastroesophageal reflux or swallowing disorders (eg in children cerebropatici). Infrequent also cystic fibrosis or cystic fibrosis, a disease that involves the glandular secretions and gives an interest and that of the respiratory tract. For that disease, in many Italian regions, is currently running at birth a highly sensitive test for which the diagnosis is already suspected in the neonatal period.
sinusitis or rhinosinusitis is more properly a widespread disease whose symptoms are dominant, as well as a persistent cough , the persistent obstruction of the nose with often dense secretion, yellow or greenish (the child "moccioloso"), halitosis. Often following a "cold" initial acute that creates conditions favoring the infection of the sinuses. It 'important to note that the headache, a symptom that the popular tradition is associated with sinusitis, is, on the contrary a rare symptom of sinusitis in children and exclusive big baby, over 10 years, when you complete the development of the frontal sinuses .
Pertussis or whooping cough or whooping cough or whooping cough is a disease whose frequency is significantly reduced with the extension of specific vaccination and now it is easier to find in pubertal age children or adolescents escaped vaccination in a ' time when it was not practiced so extensively. In our days the pertussis vaccination is between vaccinations usually carried out at the vaccination centers.
A not insignificant proportion of persistent cough, frequent cause of radiographic, allergy, laboratory, as well as repeated medical consultations, is the so-called psychogenic cough, that is, "nervous." It 'a very disturbing cough that is conceptually equivalent to a tic. Sometimes seem to be almost the parents not wanting to accept this diagnosis, as if they refused to accept the purely functional origin and at the end of a trivial disorder so great, causing much anxiety and for which so many inquiries and many therapies, useless, are been performed.

Finding your way?
The cause of a cough that persists over time can, in about 95% of cases, be identified by the doctor without an investigation and radiographs. In fact very often the diagnosis can be made ??before you even visit the child with an accurate capture of data (history) about the history of the child, the circumstances in which the cough has arisen, the character of the cough, the response to previous therapies.

Psychogenic cough

A history targeted is generally enough to recognize the cough psychogenic: it is a cough strokes isolated, throat (as if the child "raschiasse the throat"), which is accentuated in moments of tension, is reduced when the child is distracted, and typically disappear with sleep. However no cough "true", ie due to diseases of the respiratory system, from the most mundane, such as the flu, the most serious forms, disappears at night, so it's a common experience that at this time the cough is most disturbing and makes sleep very difficult. In addition, some behaviors of the child properly evaluated by the doctor can confirm this suspicion: the child with psychogenic cough, for example, coughing with his hits "isolated" often tends to cover your mouth with your hand positions which may certainly be a sign of good education but it is quite unusual in the child for cough asthma, pneumonia, sinusitis, bronchitis or whatever. Still it is very common for the child, entering the doctor's office is "present" with some cough ("cough presentation") as if to once again concentrate the attention on himself already at home with centralizes this symptom. Finally, to seal the diagnosis the complete lack of response to any treatment previously made, antibiotics, steroids, bronchodilators.
Unfortunately sometimes the problem is complicated because some of these children with psychogenic cough, allergy subjected to investigations, show some positivity to some allergen that is mistakenly thought to be responsible for the symptoms. These are cases in which the therapies do not seem to show any efficacy and cough "allergic" the child seems resistant to any appropriate treatment. Enough this fact, the lack of response to adequate treatment for allergic cough with bronchodilators and inhaled corticosteroids to exclude the allergic origin of cough and having to think of a different origin of it. Not everything that happens to an allergic child is due to his allergy.

Pertussis

For pertussis diagnosis usually precedes a visit to the child and is out of the history of cough and its characters. It 'a cough that after a period of 1-2 weeks (catarrhal period) in which it appears trivial and similar to many other toxic that the child has presented in the past begins to present (ictal period) of the special features. The child begins to have fits of coughing. The coughing is so close and numerous that the child can not, as it happens vice versa in other forms of cough, breath and then resume congested, becomes cyanotic, sometimes, fortunately rarely, fainting. The coughing usually end with a typical deep and noisy breath release (scream inhalation). The child lying in access feels the urgent need to stand up and sit up (= if you have to put a child coughing sitting thinking about whooping cough). In the weeks following access become more frequent and mainly nocturnal occur during the day. Finally after 2-3 weeks accesses become rarer and cough abates. Thus begins a long period of convalescence (the Chinese called pertussis "the cough of one hundred days") during which, however, any stimulus to cough (eg Company a trivial viral infection) can cause small accesses.
tests laboratory are not helpful for the diagnosis of this disease, which, fortunately, as mentioned, is a marked reduction statistics with the advent of extensive vaccination and is currently riscontabile more frequently in boys at that time not vaccinated.

Rhinosinusitis

For rhinosinusitis medical history, ie the collection of information on the emergence of cough, symptoms concomitant appearance of nasal secretions, may immediately, to suspect the disease. These are children who usually have started coughing during an acute infection of the upper respiratory tract with fever, cold and, of course, cough. The fever has disappeared for several days but the cough persisted and persists along with a blocked nose. Not only that, nasal secretion in the early days was clear and transparent with the days became denser and now has features frankly purulent or mucopurulent in color from yellow to green. Usually these children have breath "heavy", haloed eyes (dark circles). In most cases, the problem has been dragging on for a month or more, the child presented transient improvement during treatment with some antibiotics but after a few days the cough, stuffy nose, "the snot" dense reappeared. It 'a very typical history and diagnosis relatively simple. It can be said that there is a drastically sinusitis if symptoms cooling, cough and drainage from the nose of green mucus or purulent, persist for more than 10 days. You do not need anything else to the diagnosis of sinusitis and, above all, a habit hard to uproot, it is of no use, the X-ray of the sinuses. X-rays of the sinuses is of no use to a sum of reasons, the first of which is that with it you do not see the ethmoid sinuses are the paranasal sinuses sinusitis mainly engaged in the child. Secondly, for technical reasons and not only, with radiography are easy diagnosis excess but also in defect, in the sense that it can be diagnosed with sinusitis to those who did not, and is the most frequent occurrence, but can be excluded those who did. In other words, we explain in this way stories are distinctively adult, perennial headache due to "sinusitis" that never go out in spite of all kinds of treatment and in the first spa therapies and inhalation. It just is not sinusitis but migraine headaches, tension or anything else diagnosed "for convenience" or superficiality as sinusitis due to radiological "positive."

Asthma

-Chronic persistent cough may be the only sign of asthma and therefore allergy, as allergic asthma does not always mean. It must be said though that it is rather unlikely that the cough remains the only symptom for a long time, usually after some time the asthmatic wheezing occurs and the nature of the cough becomes clear. Then a persistent cough with wheezing does not raise doubts as to its nature, problems may occur when the cough is the only symptom.
Even in these cases, however, can help a collection of adequate information about the child, the characteristics of his cough, on seasonality, the situations in which it occurs or gets worse. For example, a family history of allergies and especially the personal history of food allergy, atopic dermatitis, positive allergy testing, allergic rhinitis can immediately orient the diagnosis, however, as I said not everything that occurs in the allergic child is always considered and only due to allergy. The asthmatic cough then certain characteristics: it is often a cough that occurs at night or early in the morning (mite allergy) and has a seasonality function of the allergen responsible. The mite allergic cough in the cold months and the cough disappears in the summer months, the child with pollen allergy cough in the spring. Finally, the asthmatic cough may occur or acute in certain situations: it can be exercise-induced cough (stress), rice (rice cough), cold from smoky environments, and moisture. The cough stress and rice, in the absence of overt symptoms of asthma express the existence of a state of minimal inflammation but persistent bronchial responsible for an abnormal bronchial reactivity ("bronchial hyperreactivity) so just rice or effort, but also a viral infection or taking an aspirin or an increase in the concentration of allergens or environmental pollution because it is not only induced cough but sometimes the asthma attack itself.

What to do?

We have already said that in 95% of cases the determination of the cause of a persistent cough does not require the use of diagnostic tools that are not an accurate collection of news from the parents and the child himself accompanied by a careful examination of the doctor. Are not necessary to first approach the child in everyday laboratory investigations, blood tests, allergy tests. A "history" is accurate in most cases already very guidance and depending of it will seek the doctor of the signs which can confirm whether or not the diagnostic orientation. In the case of asthmatic cough for example, there are several systems, some of which may be used by the parents in order to clarify the nature. Physical exertion, such as a stroke or flexing, can lead to wheezing that can sometimes be seen approaching the ear to the mouth of the child. A similar effort may be induced by the doctor while visiting compressing the child's chest breathing. In this way the doctor often, especially on the front of the chest, able to perceive with the stethoscope, the expiratory wheezing or a significant increase in the expiratory phase of breathing. Another test is the administration of the bronchodilator medication: cough-equivalent asthma responds well to treatment with inhaled bronchodilators. A positive response to their administration therefore has diagnostic significance. Vice versa has no effect on these type of cough antihistamines, as well as frequently used in these cases: the asthmatic cough is not primarily linked to the action of histamine in the body and therefore antihistamines can not be effective on this symptom.
still can be of assistance other elements such as the presence of atopic dermatitis or those signs "under atopy" such as dry, rough skin, double fold of the lower lid of the eye, the small cut at installation of the ears.
sinusitis To confirm the suspected diagnosis is sought by the doctor through observation, with a standard otoscope, nasal. The presence of yellow or greenish mucopus confirm the suspicion of maxillary sinusitis, the same test may be useful in distinguishing sinusitis cough from that allergy: allergic forms in the lining of the nose will look pale-purple and swollen and the nasal discharge be clear transparent serosa.
ethmoid sinusitis For, as has been said that the most frequent in children, examination of the throat with the light bulb and the stick tongue sometimes allow the doctor to see the lava flows of mucopus the pharynx from above ( from "nasopharynx"). It 's the mucopus that overflows from the ethmoid sinuses.

Practical behavior

In ambulatory care daily, facing a problem of persistent cough you can behave in this way, taking into account the most frequent causes of essa.1. Are first of all to be excluded, and this is possible in the majority of cases with only clinical (ie medical records + examination of the child), asthma, rhinosinusitis, cough or psychogenic nervous. Whooping cough, a common cause of persistent cough in the recent past and also just diagnosed with clinical data at the time displayed in sharp decrease statistics.
a. if there is asthma treated with inhaled corticosteroids underlying long + allergy tests (not necessarily immediately),
b. if there is sinusitis appropriate antibiotic therapy for 10-15 days + corticosteroid nasal without further examination, at least in the first episode of sinusitis: diagnoses (allergy or ENT) are indicated in case of frequent relapses or no recovery after appropriate treatment,
c . if there is psychogenic cough reassure parents and explain the functional nature of the symptom.

2. If there is asthma or rhinosinusitis or psychogenic cough you should perform a chest x-ray. Only in this case, therefore, may need a radiological assessment, unless the clinical data are not clearly subscripts for a bronchopneumonia in which case the radiographic assessment may be superfluous.

3. If the X-ray examination ruled out the presence of an outbreak of pneumonia must be considered that the child has a persistent cough due to bronchitis to mycoplasma or chlamydia or Moraxella, germs that can be tackled in a two week cycle of macrolides. Such therapy would have at this point a diagnostic significance (criterion former juvantibus).

In this way it is possible to address and resolve, at the first level, nell'ambulatorio the pediatrician, the vast majority of cases of chronic persistent cough-and avoid diagnostic process more laborious, unnecessary investigations solvents from the operational point of view, treatments often inconclusive.

Hyperexcitability syndrome of cough receptors

The SIRT (hyperexcitability syndrome of cough receptors) is a frequent cause of Appeal, by the parents, the pediatrician allergist because, in common layman heard a cough evening and night so intense allergy is often thought. The characteristics of the syndrome are:
- uncontrollable cough, shattering, hacking, in the course of usual infections of the upper airways;
- usually cough appears or gets worse asleep;
- the cough autoamplifica more the child coughs the greater the stimulus cough;
- in the same child cough is always repeated in the same way;
- are ineffective cough suppressants, corticosteroids and bronchodilator aerosol (eg Broncovaleas and Ventolin). There are asthmatics and non-asthmatics become;
- duration 3-4 days.
Behind this there is no allergy cough but a constitutional hypersensitivity of the cough receptors. Ie they are children that every time you "cool" feature, especially when they go to bed, a violent cough that seems to never stop, but rather increases more and more with the coughing. All therapies are poorly effective. The problem is solved within a few days of the course of a normal condition of type "flu."

From the therapeutic point of view the usual antitussives, inhaled corticosteroids, Broncovaleas, Ventolin are, as mentioned, usually ineffective, but the SIRT
- sometimes responds to Bentelan and Paracodina;
- may be useful "grandma's remedies"
_ decubitus raised,
_ warm milk and honey,
_ rid the nose,
_ open the windows.

It is not, needless to say, a state of allergy.
Testing capsaicin: inhalation of capsaicin leads to cough at very low doses compared to normal subjects and also for asthmatics.