Posted tagged ‘cough’

Can medicines relieve coughing?

January 4, 2016

The Pediatric Insider

© 2016 Roy Benaroch, MD

Wzrd1 asked, “What are your thoughts on expectorants?”

One of the most common reasons for office visits to me, especially in the winter, is coughing. No one really likes to cough – not the kids, and certainly not their parents. Everyone wants the coughing to stop.

First, though, think about what a cough is – it’s a forceful pop of an exhale that can bring up mucus from the airways. If you’ve got a cold with excessive mucus, or you’ve inhaled some dust, or there’s a bacterial infection with pus down in your lungs, the only way to get that stuff out is to cough it up (and, typically, swallow it back down into your stomach. From there it can be digested on its way out of your body. Isn’t science fun?) The alternative to coughing is to just let the yuck sit down there. Coughing has a purpose, and it’s a good thing.

Yeah, I know. Try telling that to a parent or child at 2 AM. Besides, no one wants a coughing person at school or at work, spraying their mucus around. I get it. So it sure would be nice to have something, anything, to at least slow that cough down some.

Now, if your child has asthma or cystic fibrosis or some other lung thing, it’s best to treat the underlying cause of the cough. For the rest of this post, I’m talking about only non-specific, mild, ordinary coughing. The kind that goes with an ordinary “cold” or “chest cold” or “bronchitis” (which, by the way, are all the same thing. But that’s a topic for another time.) If your child has a cough with a high fever or trouble breathing, or has chronic lung problems or heart disease, go get it checked out.

Most of the time, though, a cough is just a cough. Medicines available to help with cough fall into just a few categories:

Cough suppressants, like dextromethorphan (OTC) or the narcotic codeine (Rx). These either make you too sleepy to cough, or somehow “suppress” the cough centers of your brain to trick you into not coughing. Stronger ones, like codeine and similar compounds, can cause respiratory depression and death, which is bad.

Expectorants, like guaifenesin (OTC). These supposedly “thin the secretions”, making them easier to cough up. Sometimes, expectorants and suppressants are combined into one product, which I suppose makes it easier to cough while simultaneously stopping your cough. Honestly, I get a headache just thinking about why that would be a good idea.

Antihistamines, which block many allergic reactions. These will help if a cough is caused by allergy (clue: if there is also runny/itchy eyes and nose, that might be the case.) Older antihistamines like Benadryl also make people sleepy, so they won’t notice the cough. Maybe that’s good.

Do these medicines work? There are dozens of studies out there, using a variety of doses and ways to measure coughing. The bottom line, summarized here, is that better-quality studies with more-objective measures of coughing and appropriate use of placebo comparators have not consistently shown any effectiveness for any “cough medicine”, used alone or in combination. And there have been significant side effects, especially from antihistamines and narcotic-based cough suppressants.

About expectorants specifically: basic science studies, like this one, have failed to show that expectorants change the way mucus appears or is cleared by cilia. And clinical studies from the 1980’s showed no change in objective or subjective cough scores.  There have been zero—zero!—good quality studies of expectorant use in adults or children for coughing in the last 20 years. I did find one case report of a man who had improved sperm motility when he was treated for infertility with guaifenesin, but I don’t think that’s exactly what most parents are looking for.

In fact, the only positive news about cough treatment I found in the recent literature was in support of honey for the relief of coughing in children one year and up. Three good randomized trials have been published in the last few years, all showing that honey is better than either placebo or “cough medicine”.  We’re not talking honey-based “medicine”, here – that’s for sale, but you don’t need it. Just good old honey, typically from a bottle shaped like a bear. It works, it’s cheap, it’s safe for children 1 year and up. Give it a try. And teach your children to cough into their elbows. That’s honestly the best you can do.

Honey badger don't care

 

 

 

 

 

 

 

 

 

 

 

 

Recurrent wheezing in preschoolers

May 18, 2015

The Pediatric Insider

© 2015 Roy Benaroch, MD

Maura wrote: “I’d appreciate a post on treating and understanding intermittent asthma (viral induced) in preschoolers. I’m currently very confused about whether the risks and benefits of treating with inhaled steroids are well established.  I’m also confused about what the literature means when they say ‘exacerbation’ of asthma.  Thank you!”

Hoo boy. This is one of those questions that would get different answers to if you asked a room full of pediatricians. Different answers, and arguing, and maybe a thrown chair or two.

Heck, we’re not even sure if we should call this asthma. So I’ll back up to what we all can agree on, first.

A “wheeze” is a specific physical exam finding. It’s a whistly, almost musical sort of chest noise, the noise you hear when air tubes are constricted. Most (but not all) wheezing is heard during expiration. Children who are wheezing almost always cough, and cough is the main symptom of most wheezy illness. It makes sense—the airways are constricted, so the body tries to “pop” them open with a forceful expiration. Coughing can open airways and at least temporarily relieve the airway constriction and wheeze.

Lots of health conditions cause wheezing, and at least 25% of children will wheeze at least once. Mostly typically, it’s caused by a viral infection. Whatever you do or don’t do to treat it, the noise will go away and Junior will stop coughing. But recurrent episodes of wheezing, that’s when things get interesting. And controversial.

In older children, school age and up, the most common—by far—cause of recurrent wheezing is asthma.  These kids usually have multiple triggers for their wheezing, including allergies, infections, cold air, and exercise (not all kids will have all of these triggers). Albuterol is the mainstay medicine to quickly stop wheezing and coughing once it starts. Inhaled steroids are the best medicine to use to prevent wheezing flare-ups (called “exacerbations”—that’s when kids with asthma have symptoms like coughing, wheezing, chest pain, and shortness of breath.) Inhaled steroids as preventive medicines work and they’re safe. Kids with asthma who use daily inhaled steroids have far fewer exacerbations, miss less school, and stay healthier.

But there’s another group of children in whom the usefulness of inhaled are less clear-cut. These are toddlers and preschoolers, little kids, who have recurrent wheezing episodes only triggered by one thing: viral infections. They get a cold, they start to wheeze. These kids seem to respond less robustly to both inhaled albuterol (which, especially in the youngest children, may not work at all), and less well to inhaled steroids, too.

Some people don’t even think we should label these little ones with recurrent wheeze as having asthma, because that can mislead us into using treatments that are less effective. A suggested label is to say these children have “WARI”, or Wheeze Associated with Respiratory Infections. Some docs say these kids have “RAD” or reactive airways disease, or “recurrent bronchitis”, or “viral pneumonia”, or recurrent “bronchiolitis”.

What makes this especially difficult is that we can never tell, from the first or second wheeze episode, if a child is going to end up with asthma (recurrent wheeze of many triggers) versus WARI (recurrent wheeze only triggered by infections.) Some suggest we look at family history, or whether the child has eczema or food allergies, but that history doesn’t reliably predict the future course of wheezing. What we really need is some kind of test or biomarker to predict who will really benefit from inhaled steroids. We don’t have any great way to know.

Inhaled steroids are safe, at least in ordinary low doses. In higher doses some growth suppression can occur, though that may disappear with long-term use. And we know out-of-control asthma, with frequent wheezing, will also stunt growth.

As always, risks and benefits have to be weighed. If a young child has infrequent flare-ups easily treated with albuterol I’m less likely to suggest a trial of an inhaled steroid; but if flare-ups are frequent or severe or land a child in the emergency department, daily inhaled steroids are worth a try. There’s some art here, and a lot we don’t know, and plenty of room for discussion between doc and parent about what’s best for each childs’ circumstances. The chair throwing, that’s optional.

I feel a song coming on!

I feel a song coming on!

Caring for a child with croup

November 13, 2014

The Pediatric Insider

© 2014 Roy Benaroch, MD

Last time, we talked about croup—what it is, and what it isn’t. It’s a viral infection of the upper airway, usually caused by parainfluenza virus, that causes a peculiar, bark-like cough in infants and young children. Usually there’s a hoarse voice, some fever, and other minor viral symptoms like a runny nose. More-severe cases of croup include a high-pitched inhaling noise called “stridor.”

Though most children with croup do fine with home care, some kids can really get sick with this. Red flags to look out for:

  • Frequent or persistent squeaky upper-airway noise.
  • A sense that the child is really scared or upset.
  • A child who is excessively sleepy.
  • Blue color to the lips.
  • A parent who’s really worried.

If your child has one or more of these red flags, go see a doctor right away. Do not hesitate to go to the Emergency Department. Breathing is really important. If you’re worried, your child needs to be seen immediately.

Most kids, though, do not have severe disease and can be managed at home. The best “first aid” trick for croup is cold air. If it’s cool out, go outside or open a window. If it’s not cool out, put your child’s face in the freezer. I know this sounds weird, but it works. Croup is caused by swelling in the upper airway, and cold air quickly reduces that swelling.

If you don’t like the idea of cold air: try warm steam. I don’t think it works quite as well as cold air, but sitting in a steamy bathroom seems to help at least some.

Also, try to keep your child calm and content. Worrying and crying makes croup worse. Kids can pick up on worries from parents, and when any of us get anxious we can have some tightening of the throat. Keep things calm, or even pop in a favorite video as a distraction.

If your child has asthma, it may be worthwhile to at least try a breathing treatment with asthma rescue medications. Asthma and croup aren’t the same thing, but children with asthma will sometimes get a barky cough that sounds like croup. An asthma treatment isn’t going to hurt. Talk with your child’s doctor about when you ought to be using asthma medications so you’re all on the same page.

Children with croup that doesn’t respond to home care ought to go see their pediatrician or family doc. Pro tip: bring a video so we can hear what the cough really sounds like. (The cough is always better during the day when out offices are open.) We can help confirm the diagnosis, and sometimes treatment with a steroid can help shrink the upper airway and relieve the barky cough and tightness. Typical steroids used include prednisolone orally (tastes bad, but easy to find at pharmacies and cheap); dexamethosone orally (tastes fine, but you have to crush tablets—there isn’t a good practical liquid version); or dexamethasone injected (Ow! But it works!) Steroids will take the “croup” out of the croup, but will not knock out the cough completely. It’s still a viral infection, and a bit of cough and fever and runny nose are going to persist for a week or so no matter what you do.

Are all “croup coughs” caused by croup?

November 11, 2014

The Pediatric Insider

© 2014 Roy Benaroch, MD

“I had to bring my son in again for that croup cough. What does it mean if he keeps getting that?”

“Croup” is one of those funny words that different people use to mean different things. And sometimes using the word locks us into a certain specific diagnosis that might be wrong. I try to get parents to just avoid the word entirely. Instead of saying “croup”,  just tell me what the cough actually sounds like. Or better yet, bring a video.

To a pediatrician, a “croupy cough” or a “croup-like cough” is a very specific, odd sort of cough. It sounds—really—like a small dog or seal barking. It is not a deep cough (at least not the way I think of that word), nor is it “dry” or “wet” or “chesty”.

Here’s a very typical conversation:

Mom: “He’s got that croup again!”

Me: “What does the cough sound like?”

Mom: “You know, that croup cough.”

Me: “So, what does it sound like?”

Mom: “You know, all deep in his chest.”

Me: “That’s not what croup sounds like. Does it sound like a seal or a dog?”

Mom: “Yes. It’s a chesty croup cough.”

But croup doesn’t sound chesty or deep at all. Mom and I are getting tied up in the language and not really paying attention to what the child really sounds like. Conversations like these muddy the diagnosis. In my experience, most kids with recurrent “croup” don’t have recurrent croup at all—they just have a cough, and somewhere along the line someone called it croup, and that’s the diagnosis that has stuck.

Croup rule #1: Is the cough really barky, like a seal or dog? If not, it isn’t croup.

There’s more, too. Even if the cough does sound barky, your child still may not have croup. Other things cause a barky cough, too. “Croup”, the illness, is a viral infection of the upper airway usually caused by a virus called “parainfluenza” (occasionally, other viruses can cause croup, too). Other symptoms usually include a mild fever, hoarse voice, and a sore throat that’s lower down on the neck than a typical sore throat. Appetites might be low, and there will probably be some runny nose. A more-severe case of croup will be accompanied by a breathing noise called “stridor,” which is a high pitched inhaling noise that gets worse at night. A “croupy cough” that’s not accompanied by these other findings is less likely to really be a case of croup, and someone had better remember to at least think about that possibility. Other causes of croup cough can include:

  • Asthma, especially if recurrent
  • A foreign body in the airway
  • A mass in the airway
  • A loose kind of airway (some kids are born that way, and their coughs always sound kind of croupy, though it isn’t really “croup”)

Croup rule #2: Not all croupy coughs are caused by croup.

There’s no single test that definitively tells you that it’s croup. A viral swab of the nose can show if parainfluenza virus is around (though not all croup is caused by parainfluenza, and parainfluenza itself can cause infections other than croup.) An x-ray of the neck can reliably show swelling and changes that are very suggestive of croup—and can effectively “rule out” other possibilities. Sometimes a chest x-ray can be helpful, too. But the bottom line is that the diagnosis depends on the overall picture. The exact sound of the cough is important, but doesn’t make the diagnosis alone. Doctors and parents need to keep an open mind, and not label all that barks as croup.

By the way, that virus—parainfluenza—it’s confusing the way we’ve named these things. Parainfluenza has nothing much to do with influenza, which is a different virus completely. Influenza vaccines don’t prevent parainfluenza infections. Parainfluenza commonly causes croup in babies and young children, and also causes “laryngitis” (sore throat and hoarse voice) in older kids and adults. It can sometimes also cause a viral pneumonia in young people, or sometimes a wheezy chest infection called “bronchiolitis.” Yikes!

Next up: what to do when your child has the croup.

Should docs prescribe placebos for cough? The agave nectar story

November 3, 2014

The Pediatric Insider

© 2014 Roy Benaroch, MD

Coughing is among the most common symptoms that bring children to the doctor’s office. It’s an annoying symptom that disrupts the sleep of both the child and parents (though, oddly, siblings seldom complain—that may mean something.) Coughing itself is actually an essential physiologic mechanism to get dust and yuck up out of the lungs, but we all know that sometimes a little cough becomes a big or chronic cough that’s no fun at all. Big coughs also have the ability to make themselves worse though what’s called a “cough cycle”: person coughs, that irritates the throat, that triggers more mucus and more coughing, and the cycle continues. Fun!

So it’s understandable that people want some way to relieve coughs. We’re talking here about ordinary, everyday coughing—coughing that accompanies an ordinary upper respiratory infection (the common cold.) If someone is coughing because of asthma or pneumonia or croup or something like that, there’s specific therapy that ought to be given. Most coughs, though, are just coughs. And we want them to go away.

What’s available to help with coughing? Humid air from a vaporizer might help some (though some studies show warm humidity might worsen allergic coughs). At least one study showed that menthol rubs (like “Vicks VapoRub”) help, though the study itself wasn’t strong. We know that cough and cold medications commonly sold over the counter not only don’t work, but aren’t particularly safe. There are also dozens (maybe hundreds) of alt-med herby things that are sold, again with no evidence whatsoever that they work. Bottom line: we don’t have much for coughing.

One idea: honey. Honey is effective in children—two studies in 2007 and 2010 have shown it’s more effective than cough “medicine”—but can’t be used before the first birthday. It’s safe (at least past 12 months of age), it’s cheap, it’s worth a try. But what to do with coughing children less than one?

The same researchers who did the 2007 honey study just published another report, looking this time at agave syrup for cough in children 2 months to 4 years old. Agave syrup is a sweet extract from a cactus. It’s thick, like honey, and tastes good—and at least in reasonably small doses it’s safe at any age. In this study, a total of 69 babies and children with ordinary cough were randomized into three groups. One group got a small dose of agave syrup, one group got a “placebo” dose of grape-flavored water, and the third group got no intervention at all. The next evening, parents filled out a report of their assessment of cough severity.

Their study showed that all three groups had an improvement in cough the night after the study—whether given agave, placebo, or nothing at all. Though all children improved, the ones given agave or placebo improved somewhat more. There were several measures of cough, but to give you an idea, looking at the aggregate “cough score,” the improvement was about 10 for children given nothing, and about 15 for children given agave or placebo.

What does all of this mean? Bottom line: coughing gets better, whatever you do. But if parents are given instructions to do something, whether it’s agave syrup or a placebo solution, the cough seems to get better by a little more. Agave “works”, but it only works as well as the placebo, which by usual convention means it doesn’t work at all. Nonetheless, the parents in the study perceived that children given something did a little better than children given nothing.

Agave syrup is probably as safe as doing nothing. If you want to try it, go ahead. But I’m a little leery of the idea of encouraging an intervention that’s no better than placebo. I don’t like to create a dependence on medical interventions, especially ones that aren’t necessary. Parents shouldn’t feel that every medical issue needs a medicine, or a trip to the pharmacy, or even a trip to the grocery store or the “placebos-r-us” boutique. Hugs and love and comfort aren’t going to be studied, but I suspect they’re often the best medicine of all.

How long should coughs and runny noses last?

December 23, 2013

The Pediatric Insider

© 2013 Roy Benaroch, MD

Many sick visits to primary care docs, like me, are driven by just a handful of complaints, all typically caused by viral upper respiratory infections (URIs): cough, congestion, and runny noses. How long should parents expect ordinary cold symptoms to last?

Longer than you’d think.

The British Medical Journal this month published a wonderful article, titled “Duration of symptoms of respiratory tract infections in children: systematic review.  They found 48 studies of the symptoms of URIs which included systematic tracking of system duration. Only placebos or over-the-counter remedies were included—they did not include any patients treated with antibiotics. From pooling the information from all of these studies, they found that:

  • Cough usually lasted at least 10 days (that is, 50% of kids with cough were still coughing after day 10). Cough resolved in 90% of patients by day 25—meaning that 1 in 10 children were still coughing at day 26, almost 4 weeks after the start of the cold.
  • Common cold nasal symptoms resolved by day 10 in 50% of children. 90% were better by day 15.

So: ordinary colds, just ordinary viruses we all get, cause symptoms that typically last a couple of weeks, with the cough often lingering even longer. The old joke ought to be rewritten: without this prescription, your cold will last two weeks. With it, it’ll only last 14 days.

If you or your child has an icky cold, you might be tempted to see your doctor after a few days or a week. It’s probably better to wait longer—save yourself a visit, and you’ll be less likely to end up on an antibiotic that won’t do you any good anyway.

The long and winding cough

April 12, 2011

The Pediatric Insider

© 2011 Roy Benaroch, MD

Ilana wrote in, “My child has had a cough for at least a year. It comes and goes, but it’s almost always there. I don’t know if she needs a specialist or what, but we’re tired of the cough! What can we do?”

Chronic or frequent coughing is a fairly common complaint, and working out the why’s-she-coughing and the how-to-stop it isn’t always simple. Some of the most common causes I see are:

Asthma—far and away the most common cause of frequent or prolonged cough. Asthma can be a tricky diagnosis to confirm, but it’s easy to treat: so often we treat it if the history and exam are suggestive of asthma. If the child gets better, that confirms the diagnosis.

One cold after another—very common, especially in day care kids. What is perceived as one long, forever cough is really a bunch of cold viruses stacked one after another. Frustrating for all!

Allergies—more commonly causes congestion/sneezing/itchy nose, but many kids w/ allergies also cough. “Testing” for allergies has many false positives and negatives, so the best “test” is a history and physical exam.

Chronic or recurrent sinusitis—both the most undertreated and overtreated condition I see. I know that sounds weird, but it’s true. Sinusitis causes a cough from mucus drip.

Habit cough—common! Sometimes also called “psychogenic cough,” this is the cough that disappears when kids fall asleep.

Reflux—Gastroesophageal reflux can be sneaky, and can trigger a cough that’s especially bad at night, even without obvious symptoms like heartburn.

Pertussis—In many communities, “whooping cough” is making a comeback, thanks in part to families who choose not to immunize. Protect yourself and your children from this “100 day cough”—though the vaccine isn’t 100% effective, it’s the best protection we’ve got. Once the cough of pertussis sets in, no treatment is effective.

There are many other causes of cough, but almost all chronic/frequent cough in kids is from one of these things. The key to the diagnosis is almost always in the history. To help figure out the cause of cough, the most important “test” is a good, careful log. Keep track of when the cough occurs, what time of day or night, and what your child is doing during the cough. What makes it better? What makes it worse? What other symptoms might be going on, like fever, nasal drip or congestion, abdominal pain, shortness of breath? Go over the details with your pediatrician to help figure out the most-likely culprit.

Sometimes, fancier tests can help. These might include a chest x-ray, blood tests, or endoscopy. If your child does undergo these or other tests, keep track of the results to share with other specialists that might get involved. Depending on the initial impression, helpful specialists to assist with a cough workup include pulmonologists (lung specialists), ENTs (ear, nose, throat), or allergy/immunologists.

Meanwhile, help a coughing child feel better with some comfort care. Though OTC cough meds and rubs probably don’t work very well, steamy showers, a humidifier, or honey can help. Whatever the cause, coughing can irritate the throat, leading to more mucus production, more swelling, and more cough—so soothing lozenges (for older kids), popsicles, or ice cream can be far more effective than any medication. Stay away from regular use of narcotic-based prescription cough syrups, which can be habit-forming and potentially dangerous especially in young children. A cough can linger and annoy, but don’t choose a remedy that’s worse than the disease.