Question on chronic cough in kids

[EctopicFetus]

so this has come up a bit during my time in the peds ED.

Whats your opinion / standard for a 16 yr old with cough for 2 weeks, cant sleep 2ndary to cough. How about for younger kids?

I wanted to give some lortab (as I had in the past) but my attending stated that cough suppresion isnt recommended for kids.

My opinion is that if these kids are coughing for that long the least I can do is help em sleep at night. Am I missing the "huge downside"?

Your thoughts?

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[docB]

First, of course, is to rule out badness. Is your 16 yo smoking or on BCPs? Could they have a PE, TB, pneumonia, etc.?

That said, I don't see anything wrong in giving adolescents cough suppression. We all know that you can't treat kids like little adults but physiological adulthood isn't about voting ages either. I find that some pediatricians get uncomfortable about treating pain and other symptoms in kids who are basically physiologic adults.

When I was a resident I was doing a peds rotation and had a 17 yo 240 lb, 6'1" male with a kidney stone. I started working like I work every other kidney stone. It fried the pediatrician's brain. He wouldn't let me give him morphine, no IVF, no motrin, no CT. He checked a UA, scheduled an out pt IVP (this was in 2002 so CT was by then firmly the study of choice), said you can't give NSAIDS because they are "hard on the kidneys" and sent the kid home with T#3s. Fortunately the kid came back to the ED the next day and I happened to be there and we got it straightened out. Thing was the pediatrician had never seen a kidney stone 'cause kids rarely get them. He was a lot more comfortable with a septic baby than with a run of the mill kidney stone.

 

[GiJoe]

so this has come up a bit during my time in the peds ED.

Whats your opinion / standard for a 16 yr old with cough for 2 weeks, cant sleep 2ndary to cough. How about for younger kids?

I wanted to give some lortab (as I had in the past) but my attending stated that cough suppresion isnt recommended for kids.

My opinion is that if these kids are coughing for that long the least I can do is help em sleep at night. Am I missing the "huge downside"?

Your thoughts?

albuterol helps

 

[EctopicFetus]

albuterol helps

So she already had Nebs and a MDI with spacer.

Also docB, would you check a d-dimer? Even if she is sating 99-100? No risk factors etc? Just a question. I dont believe she was on OCPs.. but that would be a risk factor.

Fetus

 

[ERMudPhud]

Here they get a pertussis swab, cxr, and hydrocodone with a follow up with their PCP. I'm seeing greater than 1 positive pertussis per month at this point

 

[docB]

So she already had Nebs and a MDI with spacer.

Also docB, would you check a d-dimer? Even if she is sating 99-100? No risk factors etc? Just a question. I dont believe she was on OCPs.. but that would be a risk factor.

Fetus

I think if you can document no pleuritic pain, nl sat, no tachypnea and no tachycardia you can conclude no PE. The majority of teenage cough I see complain of pleuritic pain and if they're sick they often have some tachycardia. I'd say that if they are in that boat but have no other risk factors a neg Ddimer concludes the issue. If I think they're high risk I image them.

 

[DropkickMurphy]

Perhaps adding a long acting bronchodilator would be a good suggestion, particularly in the setting of no relief from albuterol.

 

[deleted109597]

Check for GERD.

 

[BADMD]

Just to add to the list: mycoplasma

Had that for 8 weeks in college and was coughing the whole time, until I got some erythro as a "just in case." Cleared up in 2 days.

 

[trkd]

Just to add to the list: mycoplasma

Had that for 8 weeks in college and was coughing the whole time, until I got some erythro as a "just in case." Cleared up in 2 days.

I was just about to say... what about the atypicals?? Maybe I am a newbie on the EM scene but my readings (and personal teenage years) say that the cough persists for up to 4 weeks (even after treatment). Sucks. And was always not recognized.

 

[EctopicFetus]

Just to add to the list: mycoplasma

Had that for 8 weeks in college and was coughing the whole time, until I got some erythro as a "just in case." Cleared up in 2 days.

Azithro should cover the atypicals.

 

[EctopicFetus]

Question for DocB or others. same patient. lets say 16 yr old on OCPs cough for 2 weeks, rxed with azithro, albuterol, prednisone, still coughing. Normal sats, no tachypnea, no tachycardia, no resp distress.

Send the D-Dimer? or no as vitals look good in this otherwise healthy 16 yr old?

 

[docB]

Question for DocB or others. same patient. lets say 16 yr old on OCPs cough for 2 weeks, rxed with azithro, albuterol, prednisone, still coughing. Normal sats, no tachypnea, no tachycardia, no resp distress.

Send the D-Dimer? or no as vitals look good in this otherwise healthy 16 yr old?

That's a good question. In that situation I would send the DDimer. The down side is that if it's positive I would feel obligated to get the CT. This is one of the reasons I continually say we (EPs) are expensive, poor quality primary care docs. The situation you describe could very appropriately be seen by a PMD and then referred to pulmo or given a different antibiotic or antiallergic med and followed up. In the ED we are appropriately trained to think of the worst possibility first and feel the need to ro PE.

You also have to rely on your gut and your gestalt of the patient.

 

[deleted109597]

Pertussis. Although Azithro should get it too. Maybe add some Biaxin, so that they know it is working.

 

[Apollyon]

Pertussis. Although Azithro should get it too. Maybe add some Biaxin, so that they know it is working.

Two macrolides? So, with the erythro, we complete the triple play.

Don't add Biaxin.

 

[deleted109597]

Two macrolides? So, with the erythro, we complete the triple play.

Don't add Biaxin.

Damn, forgot the italics.
I was just mentioning the awful taste that a small percentage of people get.

 

[deleted52758]

screw it, get the cxray, tell em it's viral bronchitis, give them some t3's before bed.

 

[NinerNiner999]

Check out a monospot too - could be atypical presentation...

 

[ispic]

Being in AZ and all, how 'bout coccidiomycosis?

 

[deleted6669]

assuming clear lungs how about considering a dx of sinusitis? post nasal drip worsens cough at night. z-pak is relatively poor coverage for sinusitis(per our I.D. folks) although biaxin would be ok....