Cough in Children | Archivos de Bronconeumología

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Diagnóstico y tratamiento de la tos crónica en pediatría. Arch Argent Pediatr. 2013;111:140–47." "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 2685 "Ancho" => 2797 "Tamanyo" => 503812 ] ] "descripcion" => array:1 [ "en" => "Diagnostic algorithm of chronic cough in children." ] ] ] "textoCompleto" => "IntroductionCough is a complex physiological reflex that consists of a violent expiration to release secretions, foreign matter, overcome bronchospasm or relieve diseases of the airways and protect the respiratory system.<a class="elsevierStyleCrossRefs" href="#bib0005">1,2</a> Cough receptors, located along the length of the airway from the larynx to the segmentary bronchi, are stimulated by chemical irritation, tactile stimulation and mechanical forces. The cough reflex consists of an afferent pathway, where impulses travel via the branches of the vagal and laryngeal nerves to the brainstem and are modulated in the cerebral cortex, followed by a motor efferent pathway that includes the respiratory muscles. Upper respiratory tract infections (URTI), bronchial hyperactivity (BHR), asthma, gastroesophageal reflux disease (GERD) and angiotensin converter enzyme inhibitor therapy, among others, increase the sensitivity of the cough receptors.<a class="elsevierStyleCrossRefs" href="#bib0015">3–5</a> A healthy school-aged child with no history of URTI in the previous 4 weeks can cough up to 34 times a day.<a class="elsevierStyleCrossRefs" href="#bib0030">6,7</a> However, coughing is one of the most common reasons for consultation in routine pediatric practice and becomes very worrying when it persists for a prolonged period of time; it impacts negatively on sleep and daily activities and affects the quality of life of the child and the parents or caregivers.<a class="elsevierStyleCrossRefs" href="#bib0040">8,9</a> Management of cough in children must be carried out in accordance with applicable pediatric guidelines, that are notably different from those used in adults.<a class="elsevierStyleCrossRefs" href="#bib0050">10,11</a> In recent years, specific guidelines have been developed for the management of cough in children in America,<a class="elsevierStyleCrossRef" href="#bib0060">12</a> the United Kingdom<a class="elsevierStyleCrossRef" href="#bib0065">13</a> and Australia and New Zealand.<a class="elsevierStyleCrossRef" href="#bib0070">14</a> The aim of this review is to update the evidence on the etiology, diagnosis and treatment of cough in children.Etiology of Cough in ChildrenIn pediatrics, the causes of cough vary clearly according to age, as discussed below.<a class="elsevierStyleCrossRefs" href="#bib0055">11–20</a> Exposure to tobacco smoke and other environmental contaminants and smoking by the children and adolescents themselves are a common cause of cough or the failure of cough to resolve at all ages.<a class="elsevierStyleCrossRef" href="#bib0020">4</a> Sometimes there may be more than one underlying cause, and an integral etiological approach to this disease in children is fundamental in order to assign appropriate treatment.<a class="elsevierStyleCrossRefs" href="#bib0080">16–21</a>Evaluation of the Child With CoughOne way of approaching cough in children is to evaluate it according to the length of time that symptoms have been present. Thus, cough is classified as acute, subacute or chronic.Acute CoughThe definition of acute cough varies depending on the guidelines: the US and Australian-New Zealand guidelines establish the duration of acute cough as 2 weeks,<a class="elsevierStyleCrossRefs" href="#bib0060">12,14</a> while the UK guidelines suggest 4 weeks.<a class="elsevierStyleCrossRef" href="#bib0065">13</a> In most children, cough is caused by URTI that normally resolves spontaneously. Preschoolers may have up to 8–10 episodes of URTI a year, and coughing may last for more than 2 weeks.<a class="elsevierStyleCrossRef" href="#bib0110">22</a> In this setting, the possibility of inhalation of a foreign body or bacterial infections must be taken into consideration.<a class="elsevierStyleCrossRef" href="#bib0065">13</a>Diagnostic Evaluation of Acute CoughChildren with acute cough do not generally require any complementary examination, since progress is usually self-limiting. A chest X-ray would be indicated if there is a clinical suspicion of pneumonia or a chronic respiratory disorder, hemoptysis, sudden onset of cough or an episode of choking that might suggest aspiration of a foreign body.<a class="elsevierStyleCrossRef" href="#bib0110">22</a> In this case, inspiration and expiration X-rays should be taken, and if there is a clear suspicion, a rigid bronchoscopy should be performed, although a flexible bronchoscopy may initially be considered. In this setting, the characteristics of the cough may sometimes assist in the diagnostic procedure: for example, cough accompanied by wheezing suggests asthma; a hacking or metallic cough may be indicative of tracheomalacia, laryngomalacia or croup; a paroxystic cough with or without stridor may suggest pertussoid syndromes; a staccato cough may be due to Chlamydia trachomatis or Mycoplasma pneumoniae infection; and a croaking, strident cough may be psychogenic.Treatment of Acute CoughTreatment of URTIs requires antipyretics, good hydration and aspiration of secretions. There is no placebo-controlled evidence to suggest the usefulness of antitussive syrups, antihistamines or combinations of these; indeed the adverse effects are potentially very serious, so these products should be avoided.<a class="elsevierStyleCrossRefs" href="#bib0115">23–26</a> Honey has been shown to be more effective than placebo in the treatment of cough associated with URTI.<a class="elsevierStyleCrossRef" href="#bib0135">27</a> Bronchodilators are ineffective in non-asthmatic children, and antibiotics are recommended if bacterial infection, streptococcal tonsillitis or pneumonia is suspected.<a class="elsevierStyleCrossRef" href="#bib0020">4</a> Educating the public and healthcare professionals about the natural history of cough associated with URTI is very important for avoiding unnecessary consultations and examinations, since in the majority of the cases, the cough will resolve two weeks after onset.<a class="elsevierStyleCrossRef" href="#bib0140">28</a>Subacute CoughBetween acute cough and chronic cough lies a gray area, known as subacute cough. The US and Australian-New Zealand guidelines define it as cough lasting 4 weeks<a class="elsevierStyleCrossRefs" href="#bib0060">12,14</a> and the UK guidelines set the limit at 8 weeks.<a class="elsevierStyleCrossRef" href="#bib0065">13</a> In most cases, it is caused by prolonged or overlapping URTIs or bacterial infections.<a class="elsevierStyleCrossRef" href="#bib0145">29</a> The recommended approach is observation, and if the cough persists more than 4 weeks, a chest X-ray should be performed. If it is normal, the child should be monitored up for 6–8 weeks. If it does not abate, the cough should be considered from its duration as chronic, and the appropriate diagnostic and therapeutic procedures should be initiated.Chronic CoughChronic cough in children is cough persisting more than 4 weeks, according to the US and Australian-New Zealand guidelines, or more than 8 weeks, according to the UK guidelines.<a class="elsevierStyleCrossRefs" href="#bib0060">12–14</a> The causes of chronic cough in children vary depending on age. Marchant et al.<a class="elsevierStyleCrossRef" href="#bib0085">17</a> carried out an etiological study in preschoolers with chronic cough, finding that the most common cause was persistent bacterial bronchitis (PBB) (40%). The next most common cause was spontaneously resolving prolonged or overlapping URTIs, while only 10% of cases were caused by asthma, upper airway cough syndrome or GERD. In the study by Asiloy et al.<a class="elsevierStyleCrossRef" href="#bib0080">16</a> in schoolchildren, the most common causes of cough were asthma (25%), PBB (23%), upper airways syndrome (20%) and GERD (5%). After adolescence, the causes of chronic cough are similar to those in adults.<a class="elsevierStyleCrossRefs" href="#bib0010">2,10,30,31</a>Chronic cough in children can be classified into 3 etiological groups (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>).<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005">1.Normal or expected cough: The cause is known, so the cough is considered expected and no specific studies are required.</li><li class="elsevierStyleListItem" id="lsti0010">2.Specific cough: This is cough that occurs with signs and symptoms suggesting a specific diagnosis that has been reached after thorough examination. This group includes asthma, bronchiectasis (BE), cystic fibrosis (CF), aspiration of a foreign body, aspirative symptoms, atypical respiratory infections, cardiac abnormalities and pulmonary interstitial disease, among others (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>).<a class="elsevierStyleCrossRef" href="#bib0160">32</a><elsevierMultimedia ident="tbl0005"></elsevierMultimedia></li><li class="elsevierStyleListItem" id="lsti0015">3.Non-specific cough: This includes syndromes that present with predominantly dry isolated cough, with no signs or symptoms suggestive of disease in a child who feels well and in whom complementary studies (at least spirometry, if feasible, and chest X-ray) are normal.<a class="elsevierStyleCrossRefs" href="#bib0055">11–13</a> In most cases, it is secondary to protracted URTI, it is not serious and resolves spontaneously. Sometimes persistent cough is due to an increase in sensitivity of the cough receptors after a viral infection,<a class="elsevierStyleCrossRef" href="#bib0025">5</a> but factors such as environmental contamination and exposure to tobacco smoke may be observed in this entity, and may contribute to its persistence.<a class="elsevierStyleCrossRef" href="#bib0165">33</a> Many of these cases are treated incorrectly with inhaled corticosteroids, having been classified as “cough variant asthma”.<a class="elsevierStyleCrossRefs" href="#bib0020">4,34,35</a></li></ul><elsevierMultimedia ident="fig0005"></elsevierMultimedia>Diagnostic Evaluation of Chronic CoughThe time and evolution, type of cough, diurnal pattern, aggravating factors and triggers, quality of the cough (dry or productive) and associated symptoms should be evaluated from the clinical records<a class="elsevierStyleCrossRefs" href="#bib0020">4,36,37</a> (<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>). It is essential that the characteristics of the cough, whether dry or productive, are evaluated, since productive, purulent chronic cough is pathological and requires investigation for suppurative diseases. If cough is accompanied by wheezing or breathing difficulties, the spectrum of possible etiological causes is wide: asthma, foreign body, recurrent aspirations, tracheobronchomalacia, bronchiolitis obliterans, interstitial diseases, chronic pulmonary disease in pre-term infants and heart diseases, among others. When it is associated with atopic dermatitis, allergic rhinitis or sensitivity to allergens, personal and family history of allergy or asthma, occurs at night and is exacerbated with exercise, cold or exposure to irritants or allergens, a diagnosis of asthma is more probable.<a class="elsevierStyleCrossRef" href="#bib0175">35</a> If hemoptysis is observed, pneumonia, pulmonary abscesses, BE, CF, foreign bodies, tuberculosis, pulmonary hemosiderosis, tumors, pulmonary hypertension or pulmonary arteriovenous malformations must be excluded. Nasal obstruction, mucopurulent rhinorrhea and halitosis would suggest upper airway cough syndrome or posterior nasal drip.<a class="elsevierStyleCrossRef" href="#bib0190">38</a> Persistent headache may be a symptom of sinusitis.<a class="elsevierStyleCrossRef" href="#bib0195">39</a> Recurrent febrile syndrome, general malaise, constitutional symptoms and a generally productive cough would indicate the need for a contact study to rule out tuberculosis.<a class="elsevierStyleCrossRef" href="#bib0200">40</a> In aspirative syndromes, cough is generally associated with food-related regurgitation and choking.<a class="elsevierStyleCrossRef" href="#bib0205">41</a> Psychogenic cough is dry, hacking, repetitive and frequent during the day, and calms down or disappears during sleep; it is exacerbated in the presence of parents or caregivers and diminishes with distraction and sport. It is diagnosed exclusively in a healthy child who does not improve with medication.<a class="elsevierStyleCrossRefs" href="#bib0095">19,20</a> Finally, to guide diagnosis, it is always important to determine if the patient has received any type of treatment and what effect it has had on the cough, to enquire about environmental factors (smoking in the family, daycare attendance, animals, environmental irritants, etc.) and to look for alarm signs or symptoms (neonatal onset, cough during feeding, cough with sudden onset, suppurative cough with expectoration, nocturnal sweating, associated weight loss or signs of chronic pulmonary disease, etc.). Alarm signs and symptoms in the study of children with chronic cough are listed in <a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>.<elsevierMultimedia ident="tbl0010"></elsevierMultimedia><elsevierMultimedia ident="tbl0015"></elsevierMultimedia>Physical examination must be complete and detailed, including the ear, nose and throat. Diagnostic tests should be requested after a full history and clinical examination have been obtained.<a class="elsevierStyleCrossRefs" href="#bib0050">10,15</a> Chest X-ray is the first study<a class="elsevierStyleCrossRefs" href="#bib0060">12,13,36</a> and, depending on the results, the following tests should be considered (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>).<ul class="elsevierStyleList" id="lis0010"><li class="elsevierStyleListItem" id="lsti0020">a.Laboratory tests: full blood panel with immunoglobulins, in case of suspected immunodeficiencies in children with cough and recurrent bacterial infections.<a class="elsevierStyleCrossRef" href="#bib0180">36</a></li><li class="elsevierStyleListItem" id="lsti0025">b.Skin tests: tuberculin sensitivity test, sweat test (electrolytes in sweat with determination of chloride) and allergy study.<a class="elsevierStyleCrossRef" href="#bib0065">13</a></li><li class="elsevierStyleListItem" id="lsti0030">c.Microbiological study: sputum or nasopharyngeal aspirate culture for study of respiratory viruses, bacterial cultures and/or cellularity studies.<a class="elsevierStyleCrossRefs" href="#bib0060">12–14</a></li><li class="elsevierStyleListItem" id="lsti0035">d.Other radiological studies: chest X-ray in inspiration and expiration in case of suspected foreign body. High-resolution computed axial tomography for suspected suppurative diseases, pulmonary malformations or severe infections. Upper gastrointestinal transit (UGT) for suspected foreign bodies in the esophagus, tracheoesophageal fistulas and extrinsic compressions.<a class="elsevierStyleCrossRefs" href="#bib0060">12–14</a></li><li class="elsevierStyleListItem" id="lsti0040">e.Pulmonary function: spirometry can be carried out from the age of 3–4 years with appropriate training. A positive bronchodilator test suggests asthma, but to reach a diagnosis, complementary studies (metacholine, exhaled nitric oxide or induced sputum) are required when it is normal.<a class="elsevierStyleCrossRefs" href="#bib0065">13,42</a></li><li class="elsevierStyleListItem" id="lsti0045">f.Fiberoptic bronchoscopy: this should be performed in all children with chronic cough and suspicion of airway abnormalities, foreign body inhalation, aspirations, if localized radiological changes are observed or for performing bronchoalveolar lavage and microbiological studies.<a class="elsevierStyleCrossRefs" href="#bib0060">12,13,39</a></li><li class="elsevierStyleListItem" id="lsti0050">g.pH monitoring: this should be performed if GERD is suspected, even though normal results do not exclude the presence of non-acid reflux, which should be evaluated with impedance testing.<a class="elsevierStyleCrossRefs" href="#bib0065">13,38,43</a></li></ul><elsevierMultimedia ident="fig0010"></elsevierMultimedia>Most Common Diagnoses of Chronic Cough in ChildrenAsthma. Children with asthma can begin with cough, but most children with non-specific cough do not have asthma.<a class="elsevierStyleCrossRef" href="#bib0220">44</a> Recurrent dry cough may be due to increased sensitivity of cough receptors,<a class="elsevierStyleCrossRef" href="#bib0025">5</a> frequently caused by URTI. BHR is associated with wheezing but not with persistent dry cough or nocturnal cough.<a class="elsevierStyleCrossRef" href="#bib0225">45</a> Risk factors, the characteristics of the cough, presence of wheezing and spirometry can assist in reaching a diagnosis.<a class="elsevierStyleCrossRefs" href="#bib0065">13,14,35,42</a>Persistent Bacterial Bronchitis. Until recently, persistent bacterial bronchitis was understudied and underdiagnosed. It is defined as productive chronic cough secondary to airway infection that resolves with long-term antibiotic treatment, after other diseases have been ruled out.<a class="elsevierStyleCrossRef" href="#bib0230">46</a> The most commonly involved microorganisms are Streptococcus pneumoniae, Haemophilus influenzae and Moraxella catarrhalis, and in some cases, more than one pathogen is isolated.<a class="elsevierStyleCrossRefs" href="#bib0145">29,47</a> Definitive diagnosis is carried out by bronchoscopy and bronchoalveolar lavage, but administration of antibiotics for 2–4 weeks can be tried to see if the clinical picture resolves before carrying out a bronchoscopy. Some patients with recurrent PBB require long and repeated cycles of antibiotics, for which reason some authors propose the possibility of long-term treatment with inhaled antibiotics.<a class="elsevierStyleCrossRef" href="#bib0240">48</a> This is a disease entity that may be associated with asthma and involves a high level of morbidity, so it should be diagnosed and treated appropriately to avoid it progressing to BE.Upper Airway Cough Syndrome or Posterior Nasal Drip. This is one of the main causes of chronic cough in adults, but it is less common in the pediatric population.<a class="elsevierStyleCrossRef" href="#bib0075">15</a> It is due to mechanical stimulation of the afferent branch of the cough reflex in the upper airway by secretions that descend from the nose and/or the paranasal sinuses. In preschoolers, it is caused by repeated infections due to adenotonsillar hypertrophy and/or seromucous otitis. In schoolchildren, persistent rhinitis and/or turbinate hypertrophy should suggest atopy, and if nasal polyps are observed, CF should be ruled out.<a class="elsevierStyleCrossRefs" href="#bib0010">2,49</a>Gastroesophageal Reflux Disease. The association between GERD and non-specific chronic cough in children is widely debated, since there is little evidence that this disease alone causes cough.<a class="elsevierStyleCrossRef" href="#bib0160">32</a> For the determination of acid GERD, 24-h pH testing is sensitive and specific, while impedance is required for the diagnosis of non-acid GERD.<a class="elsevierStyleCrossRef" href="#bib0150">30</a> UGT assists in the diagnosis of vascular rings and other causes of mechanical compression.<a class="elsevierStyleCrossRefs" href="#bib0060">12–14</a>Functional Respiratory Disorders. It is important to recognize psychogenic cough and other functional respiratory disorders in pediatric patients, since they are difficult to diagnose and are frequently labeled as asthma or upper airway cough syndrome. Psychogenic cough is less common in males, and generally occurs in schoolchildren or teenagers who, after a URTI, begin with a dry, harsh, croaking cough that occurs intermittently during the day but then disappears when the subject is distracted or sleeping. It is generally very alarming for parents, teachers and others to observe, but the patient is usually surprisingly indifferent.<a class="elsevierStyleCrossRefs" href="#bib0095">19,20</a>Treatment of Chronic Cough in ChildrenChronic cough should be treated after a thorough etiological study, the aim being to eliminate the causative agent, following clinical practice guidelines.<a class="elsevierStyleCrossRefs" href="#bib0060">12–14</a> The family must be reminded to avoid exposing the child to tobacco smoke and other environmental irritants.<a class="elsevierStyleCrossRef" href="#bib0075">15</a>Treatment of Specific Cough. Chronic cough due to asthma requires treatment with bronchodilators and, depending on classification, with inhaled corticosteroids.<a class="elsevierStyleCrossRef" href="#bib0210">42</a> In cases of allergic rhinitis, antihistamines and nasal steroids will be required.<a class="elsevierStyleCrossRef" href="#bib0190">38</a> Sinusitis will require treatment with antibiotics.<a class="elsevierStyleCrossRef" href="#bib0195">39</a> GERD should be treated with proton pump inhibitors and/or surgery.<a class="elsevierStyleCrossRef" href="#bib0250">50</a> PBB needs long-term treatment (between 2 and 6 weeks) with amoxicillin–clavulanate or clarithromycin.<a class="elsevierStyleCrossRefs" href="#bib0145">29,46–48</a> Psychogenic cough requires investigation of the causes of stress or anxiety and subsequent psychological support.<a class="elsevierStyleCrossRefs" href="#bib0060">12–14,19,20</a>Treatment of Non-specific Cough. If the cough has a moderate impact, there is no underlying disease and the child is healthy, a period of observation is recommended before diagnostic tests or treatment are initiated, with a follow-up examination of the child after 6–8 weeks. If a decision is taken to carry out a trial treatment, the duration should be empiric and based on the recommendations of experts, given the lack of controlled studies in the pediatric population.<a class="elsevierStyleCrossRefs" href="#bib0020">4,12,16</a> A trial treatment with inhaled corticosteroids at half doses is recommended for predominantly dry cough (budesonide 400μg/day or equivalent) for 2–12 weeks, depending on the guidelines. The patient should be reassessed after 2–3 weeks and if there has been no response to treatment, it should be discontinued<a class="elsevierStyleCrossRefs" href="#bib0060">12,13</a> (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>). In cases of non-specific productive cough, initiating a course of antibiotics (amoxicillin–clavulanate) for 2–3 weeks may be considered. Chang et al.<a class="elsevierStyleCrossRef" href="#bib0255">51</a> carried out a study in children with cough of more than 4 weeks’ duration, who were randomized to follow a previously defined treatment algorithm after 4 weeks or to continue the untreated observation period for 6–8 weeks. The primary endpoint of the study was resolution of cough at 6 weeks. The duration of cough was shorter in the early treatment group. In some patients, cough resolves spontaneously, irrespective of treatment, and the diagnosis of cough as “cough variant asthma” can only be established if symptoms recur after treatment withdrawal and respond again after it is reintroduced, so a positive response with inhaled corticosteroids does not confirm the diagnosis of asthma. The use of central action antitussives, non-opiate antitussives, mucolytics or expectorants is not indicated.<a class="elsevierStyleCrossRef" href="#bib0020">4</a> The presence of more than one cause of cough may lead to a delay in response or treatment failure if underlying conditions are not treated.<elsevierMultimedia ident="fig0015"></elsevierMultimedia>ConclusionsCough in childhood is a common symptom that, in most cases, is due to banal respiratory infections, but all children with chronic cough must be thoroughly studied to determine the underlying cause. Detailed history and physical examinations, with chest X-ray and spirometry (if possible) are recommended. Specific chronic cough should be treated according to the underlying disease. If diagnosis is unclear, the characteristics of the cough, whether dry or productive, can help in evaluating possible treatment: inhaled corticosteroids for dry cough or antibiotics for productive cough. If no improvement is observed, these treatments should be discontinued and alternative diagnoses explored, bearing in mind that in some cases the cause of cough may be more than one disease. There is no evidence that the use of antitussive syrups and/or antihistamines or other cough remedies are effective, and, with the exception of honey for URTI, they may have serious adverse effects in children, so they must not be used.FundingThis review was conducted without funding.Conflict of InterestsThe authors state that they have no conflict of interest." "textoCompletoSecciones" => array:1 [ "secciones" => array:11 [ 0 => array:2 [ "identificador" => "xres349276" "titulo" => "Abstract" ] 1 => array:2 [ "identificador" => "xpalclavsec330937" "titulo" => "Keywords" ] 2 => array:2 [ "identificador" => "xres349275" "titulo" => "Resumen" ] 3 => array:2 [ "identificador" => "xpalclavsec330938" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Etiology of Cough in Children" ] 6 => array:3 [ "identificador" => "sec0015" "titulo" => "Evaluation of the Child With Cough" "secciones" => array:3 [ 0 => array:3 [ "identificador" => "sec0020" "titulo" => "Acute Cough" "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0025" "titulo" => "Diagnostic Evaluation of Acute Cough" ] 1 => array:2 [ "identificador" => "sec0030" "titulo" => "Treatment of Acute Cough" ] ] ] 1 => array:2 [ "identificador" => "sec0035" "titulo" => "Subacute Cough" ] 2 => array:3 [ "identificador" => "sec0040" "titulo" => "Chronic Cough" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0045" "titulo" => "Diagnostic Evaluation of Chronic Cough" ] 1 => array:2 [ "identificador" => "sec0050" "titulo" => "Most Common Diagnoses of Chronic Cough in Children" ] 2 => array:2 [ "identificador" => "sec0080" "titulo" => "Treatment of Chronic Cough in Children" ] ] ] ] ] 7 => array:2 [ "identificador" => "sec0095" "titulo" => "Conclusions" ] 8 => array:2 [ "identificador" => "sec0100" "titulo" => "Funding" ] 9 => array:2 [ "identificador" => "sec0105" "titulo" => "Conflict of Interests" ] 10 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2013-04-19" "fechaAceptado" => "2013-09-19" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec330937" "palabras" => array:5 [ 0 => "Cough" 1 => "Children" 2 => "Protracted bacterial bronchitis" 3 => "Asthma" 4 => "Gastrooesophageal reflux" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec330938" "palabras" => array:5 [ 0 => "Tos" 1 => "Niños" 2 => "Bronquitis bacteriana persistente" 3 => "Asma" 4 => "Reflujo gastroesofágico" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "Cough during childhood is very common, and is one of the most frequent reasons for consultation in daily pediatric practice. The causes differ from those in adults, and specific pediatric guidelines should be followed for correct diagnosis and treatment. The most common cause of cough in children is viral infection producing “normal cough”, but all children with persistent cough, i.e. a cough lasting more than 4–8weeks or “chronic cough”, must be carefully evaluated in other to rule out specific causes that may include the entire pediatric pulmonology spectrum. The treatment of cough should be based on the etiology. Around 80% of cases can be diagnosed using an optimal approach, and treatment will be effective in 90% of them. In some cases of “nonspecific chronic cough”, in which no underlying condition can be found, empirical treatment based on the cough characteristics may be useful. There is no scientific evidence to justify the use of over-the-counter cough remedies (anti-tussives, mucolytics and/or antihistamines), as they could have potentially serious side effects, and thus should not be prescribed in children." ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "La tos en la infancia es un síntoma muy frecuente, y constituye uno de los motivos de consulta más comunes en la práctica pediátrica diaria. Las causas de tos en el niño son diferentes a las del adulto y se deben seguir las guías específicas de la edad pediátrica para su diagnóstico y tratamiento. En la mayoría de casos la causa son infecciones respiratorias banales que producen una «tos normal o esperada», pero todo niño con tos que persiste más allá de las 4 a 8semanas se considera que tiene «tos crónica» y debe ser evaluado para descartar patologías específicas que abarcan todo el espectro de la neumología pediátrica. El tratamiento de la tos debe realizarse en función de la etiología. Con un abordaje adecuado se puede identificar la misma hasta en el 80% de los casos y el tratamiento será efectivo en el 90% de ellos. En algunos casos de «tos crónica inespecífica», tos en la que se ha descartado patología subyacente, se puede realizar un tratamiento empírico en función de las características de la tos. No hay evidencia científica que justifique el empleo de tratamientos sintomáticos que alivien la tos, como jarabes antitusivos, mucolíticos y/o antihistamínicos, ya que pueden tener efectos secundarios potencialmente graves, por lo que no se deben emplear." ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "Please cite this article as: Lamas A, Ruiz de Valbuena M, Máiz L. Tos en el niño. Arch Bronconeumol. 2014;50:294–300." ] ] "multimedia" => array:6 [ 0 => array:8 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "fuente" => "Taken from Chang AB. Causes, assessment and measurements in children. In: Chung FK, Widdicombe JG, Boushey HA, editors. Cough: causes, mechanisms and therapy. London UK: Blackwell Science; 2003:57–73." "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1592 "Ancho" => 2087 "Tamanyo" => 167119 ] ] "descripcion" => array:1 [ "en" => "Classification of chronic cough by etiology." ] ] 1 => array:8 [ "identificador" => "fig0010" "etiqueta" => "Fig. 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "fuente" => "Taken from Saranz R. Diagnóstico y tratamiento de la tos crónica en pediatría. Arch Argent Pediatr. 2013;111:140–47." "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 2685 "Ancho" => 2797 "Tamanyo" => 503812 ] ] "descripcion" => array:1 [ "en" => "Diagnostic algorithm of chronic cough in children." ] ] 2 => array:7 [ "identificador" => "fig0015" "etiqueta" => "Fig. 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 1227 "Ancho" => 2094 "Tamanyo" => 204597 ] ] "descripcion" => array:1 [ "en" => "Chronic non-specific cough treatment algorithm. IC: inhaled corticosteroids." ] ] 3 => array:7 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:2 [ "leyenda" => "BE: bronchiectasis; C. trachomatis: Chlamydia trachomatis; PCD: primary ciliary dyskinesia; CF: cystic fibrosis; M. pneumoniae: Mycoplasma pneumoniae." "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Chronic cough in healthy children \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Chronic cough in children with pulmonary disease \t\t\t\t\t\t\n \t\t\t\t</td></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Repeated respiratory infections \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Suppurative diseases: CF, BE or PCD \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Persistent bacterial bronchitis \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Immunodeficiencies \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Upper airway cough syndrome or post-nasal drip \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Aspirative syndromes \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Cough-variant asthma \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Aspiration of foreign body \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Psychogenic cough \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Infections: Mycoplasma pneumoniae, Chlamydia trachomatis, tuberculosis, pneumonia, etc. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Irritative cough (tobacco or other irritants) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Congenital abnormalities: trachoesophageal fistula, vascular rings, airway malformations, neuromuscular diseases, etc. \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab521239.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Differential Diagnosis of Specific Causes of Chronic Cough in Children." ] ] 4 => array:7 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:2 [ "leyenda" => "PBB: persistent bacterial bronchitis; BE: bronchiectasis; PCD: primary ciliary dyskinesia; CF: cystic fibrosis; ENT: ear, nose, throat; TB: tuberculosis; HIV: human immunodeficiency virus." "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Clinical history \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Remarks \t\t\t\t\t\t\n \t\t\t\t</td></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Nature of the cough</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Severity \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Rule out potentially serious specific diseases \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Time of appearance \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Causes of cough vary with age \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Diurnal variability \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Nocturnal cough is more common with asthma or rhinitis \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Sputum production \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Evaluate suppurative diseases: CF, BE, PCD, PBB, etc. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Associated wheezing \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Evaluate asthma \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Appearance or non-appearance of cough during sleep \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Psychogenic cough does not generally appear during sleep \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Hemoptysis \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Suppurative diseases, malformations, bronchitis \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"></td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Time since onset \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Allows cough to be classified as acute, subacute and chronic \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Type of cough \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Metallic, hacking, dry, spasmodic, staccato, paroxystic, etc. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Age at onset \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Neonatal onset; congenital malformations or neuromuscular diseases \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"></td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Relation with feeding or swallowing \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Possible aspirative syndrome \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Fever \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Exclude infectious disease \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Contact with TB and or HIV \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Exclude these diseases \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Chronic symptoms of ENT disease \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Evaluate the possibility of PCD, chronic ENT diseases \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Aspiration of foreign body \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Consider always in case of sudden onset cough \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Improvement of clinical symptoms with medication \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Evaluate improvement after administration of bronchodilators or antibiotics \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Exposure to tobacco smoke \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Evaluate if failure to resolve or protracted resolution \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Triggering factors \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Cold, temperature changes, exercise, exposure to allergens \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Immunological status and recurrent infectious disease \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Evaluate the possibility of immunodeficiencies \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Drug use \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Evaluate the possibility of treatment with angiotensin converting enzyme inhibitors or others \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">History of atopy or chronic diseases \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Possibility of asthma, CT, PCD, BE, etc. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Growth and development \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Evaluate immunodeficiencies, congenital diseases. \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab521241.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Key Points in the Clinical History of the Child With Chronic Cough." ] ] 5 => array:7 [ "identificador" => "tbl0015" "etiqueta" => "Table 3" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:2 [ "leyenda" => "PBB: persistent bacterial bronchitis; BE: bronchiectasis; PCD: primary ciliary dyskinesia; CF: cystic fibrosis." "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Alarm signs and symptoms \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Remarks \t\t\t\t\t\t\n \t\t\t\t</td></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Abnormal auscultation \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Asthma, bronchitis, foreign body, CF, congenital abnormalities \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Productive cough \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Suppurative diseases (CF, BE, PCD, PBB, etc.), bronchitis \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Sudden onset of cough after episode of choking \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Aspiration of foreign body \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Cough associated with food or swallowing \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Aspirative syndromes \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Chronic dyspnea \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Chest disease (airway or parenchyma), heart disease, etc. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Dyspnea with exercise \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Asthma, pulmonary disease, etc. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Heart murmur \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Heart disease \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Neurological disease \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Expirative syndromes, muscle weakness, etc. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Chest wall deformities \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Malformations, severe chronic pulmonary disease \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Hemoptysis \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Suppurative disease, vascular abnormalities, malformations, etc. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Recurrent pneumonia \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Asthma, foreign body, malformations, immunodeficiencies \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Failure to thrive \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Pulmonary or heart disease, etc. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Acropachy \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Pulmonary disease, suppurative disease, heart disease, etc. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Comorbidities \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Chronic diseases \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab521240.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Alarm Signs and Symptoms in Children With Chronic Cough." ] ] ] "bibliografia" => array:2 [ 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Review

Cough in Children

Tos en el niño

Adelaida Lamasa,b,c,

Corresponding author

adelaida.lamas@salud.madrid.org

Corresponding author.

, Marta Ruiz de Valbuenaa,b,c, Luis Máizb,c

a Sección de Neumología Pediátrica, Hospital Universitario Ramón y Cajal, Madrid, Spain

b Unidad de Fibrosis Quística, Hospital Universitario Ramón y Cajal, Madrid, Spain

c Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), Hospital Universitario Ramón y Cajal, Madrid, Spain

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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Cough is a complex physiological reflex that consists of a violent expiration to release secretions&#44; foreign matter&#44; overcome bronchospasm or relieve diseases of the airways and protect the respiratory system&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;2</span></a> Cough receptors&#44; located along the length of the airway from the larynx to the segmentary bronchi&#44; are stimulated by chemical irritation&#44; tactile stimulation and mechanical forces&#46; The cough reflex consists of an afferent pathway&#44; where impulses travel via the branches of the vagal and laryngeal nerves to the brainstem and are modulated in the cerebral cortex&#44; followed by a motor efferent pathway that includes the respiratory muscles&#46; Upper respiratory tract infections &#40;URTI&#41;&#44; bronchial hyperactivity &#40;BHR&#41;&#44; asthma&#44; gastroesophageal reflux disease &#40;GERD&#41; and angiotensin converter enzyme inhibitor therapy&#44; among others&#44; increase the sensitivity of the cough receptors&#46;<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3&#8211;5</span></a> A healthy school-aged child with no history of URTI in the previous 4 weeks can cough up to 34 times a day&#46;<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6&#44;7</span></a> However&#44; coughing is one of the most common reasons for consultation in routine pediatric practice and becomes very worrying when it persists for a prolonged period of time&#59; it impacts negatively on sleep and daily activities and affects the quality of life of the child and the parents or caregivers&#46;<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">8&#44;9</span></a> Management of cough in children must be carried out in accordance with applicable pediatric guidelines&#44; that are notably different from those used in adults&#46;<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">10&#44;11</span></a> In recent years&#44; specific guidelines have been developed for the management of cough in children in America&#44;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a> the United Kingdom<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a> and Australia and New Zealand&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a> The aim of this review is to update the evidence on the etiology&#44; diagnosis and treatment of cough in children&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Etiology of Cough in Children</span><p id="par0010" class="elsevierStylePara elsevierViewall">In pediatrics&#44; the causes of cough vary clearly according to age&#44; as discussed below&#46;<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">11&#8211;20</span></a> Exposure to tobacco smoke and other environmental contaminants and smoking by the children and adolescents themselves are a common cause of cough or the failure of cough to resolve at all ages&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> Sometimes there may be more than one underlying cause&#44; and an integral etiological approach to this disease in children is fundamental in order to assign appropriate treatment&#46;<a class="elsevierStyleCrossRefs" href="#bib0080"><span class="elsevierStyleSup">16&#8211;21</span></a></p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Evaluation of the Child With Cough</span><p id="par0015" class="elsevierStylePara elsevierViewall">One way of approaching cough in children is to evaluate it according to the length of time that symptoms have been present&#46; Thus&#44; cough is classified as acute&#44; subacute or chronic&#46;</p><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Acute Cough</span><p id="par0020" class="elsevierStylePara elsevierViewall">The definition of acute cough varies depending on the guidelines&#58; the US and Australian-New Zealand guidelines establish the duration of acute cough as 2 weeks&#44;<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">12&#44;14</span></a> while the UK guidelines suggest 4 weeks&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a> In most children&#44; cough is caused by URTI that normally resolves spontaneously&#46; Preschoolers may have up to 8&#8211;10 episodes of URTI a year&#44; and coughing may last for more than 2 weeks&#46;<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">22</span></a> In this setting&#44; the possibility of inhalation of a foreign body or bacterial infections must be taken into consideration&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a></p><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Diagnostic Evaluation of Acute Cough</span><p id="par0025" class="elsevierStylePara elsevierViewall">Children with acute cough do not generally require any complementary examination&#44; since progress is usually self-limiting&#46; A chest X-ray would be indicated if there is a clinical suspicion of pneumonia or a chronic respiratory disorder&#44; hemoptysis&#44; sudden onset of cough or an episode of choking that might suggest aspiration of a foreign body&#46;<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">22</span></a> In this case&#44; inspiration and expiration X-rays should be taken&#44; and if there is a clear suspicion&#44; a rigid bronchoscopy should be performed&#44; although a flexible bronchoscopy may initially be considered&#46; In this setting&#44; the characteristics of the cough may sometimes assist in the diagnostic procedure&#58; for example&#44; cough accompanied by wheezing suggests asthma&#59; a hacking or metallic cough may be indicative of tracheomalacia&#44; laryngomalacia or croup&#59; a paroxystic cough with or without stridor may suggest pertussoid syndromes&#59; a staccato cough may be due to <span class="elsevierStyleItalic">Chlamydia trachomatis</span> or <span class="elsevierStyleItalic">Mycoplasma pneumoniae</span> infection&#59; and a croaking&#44; strident cough may be psychogenic&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Treatment of Acute Cough</span><p id="par0030" class="elsevierStylePara elsevierViewall">Treatment of URTIs requires antipyretics&#44; good hydration and aspiration of secretions&#46; There is no placebo-controlled evidence to suggest the usefulness of antitussive syrups&#44; antihistamines or combinations of these&#59; indeed the adverse effects are potentially very serious&#44; so these products should be avoided&#46;<a class="elsevierStyleCrossRefs" href="#bib0115"><span class="elsevierStyleSup">23&#8211;26</span></a> Honey has been shown to be more effective than placebo in the treatment of cough associated with URTI&#46;<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">27</span></a> Bronchodilators are ineffective in non-asthmatic children&#44; and antibiotics are recommended if bacterial infection&#44; streptococcal tonsillitis or pneumonia is suspected&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> Educating the public and healthcare professionals about the natural history of cough associated with URTI is very important for avoiding unnecessary consultations and examinations&#44; since in the majority of the cases&#44; the cough will resolve two weeks after onset&#46;<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">28</span></a></p></span></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Subacute Cough</span><p id="par0035" class="elsevierStylePara elsevierViewall">Between acute cough and chronic cough lies a gray area&#44; known as subacute cough&#46; The US and Australian-New Zealand guidelines define it as cough lasting 4 weeks<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">12&#44;14</span></a> and the UK guidelines set the limit at 8 weeks&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a> In most cases&#44; it is caused by prolonged or overlapping URTIs or bacterial infections&#46;<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">29</span></a> The recommended approach is observation&#44; and if the cough persists more than 4 weeks&#44; a chest X-ray should be performed&#46; If it is normal&#44; the child should be monitored up for 6&#8211;8 weeks&#46; If it does not abate&#44; the cough should be considered from its duration as chronic&#44; and the appropriate diagnostic and therapeutic procedures should be initiated&#46;</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Chronic Cough</span><p id="par0040" class="elsevierStylePara elsevierViewall">Chronic cough in children is cough persisting more than 4 weeks&#44; according to the US and Australian-New Zealand guidelines&#44; or more than 8 weeks&#44; according to the UK guidelines&#46;<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">12&#8211;14</span></a> The causes of chronic cough in children vary depending on age&#46; Marchant et al&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a> carried out an etiological study in preschoolers with chronic cough&#44; finding that the most common cause was persistent bacterial bronchitis &#40;PBB&#41; &#40;40&#37;&#41;&#46; The next most common cause was spontaneously resolving prolonged or overlapping URTIs&#44; while only 10&#37; of cases were caused by asthma&#44; upper airway cough syndrome or GERD&#46; In the study by Asiloy et al&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a> in schoolchildren&#44; the most common causes of cough were asthma &#40;25&#37;&#41;&#44; PBB &#40;23&#37;&#41;&#44; upper airways syndrome &#40;20&#37;&#41; and GERD &#40;5&#37;&#41;&#46; After adolescence&#44; the causes of chronic cough are similar to those in adults&#46;<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#44;10&#44;30&#44;31</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">Chronic cough in children can be classified into 3 etiological groups &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46;<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">1&#46;</span><p id="par0050" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Normal or expected cough&#58;</span> The cause is known&#44; so the cough is considered expected and no specific studies are required&#46;</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">2&#46;</span><p id="par0055" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Specific cough&#58;</span> This is cough that occurs with signs and symptoms suggesting a specific diagnosis that has been reached after thorough examination&#46; This group includes asthma&#44; bronchiectasis &#40;BE&#41;&#44; cystic fibrosis &#40;CF&#41;&#44; aspiration of a foreign body&#44; aspirative symptoms&#44; atypical respiratory infections&#44; cardiac abnormalities and pulmonary interstitial disease&#44; among others &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">32</span></a></p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">3&#46;</span><p id="par0060" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Non-specific cough&#58;</span> This includes syndromes that present with predominantly dry isolated cough&#44; with no signs or symptoms suggestive of disease in a child who feels well and in whom complementary studies &#40;at least spirometry&#44; if feasible&#44; and chest X-ray&#41; are normal&#46;<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">11&#8211;13</span></a> In most cases&#44; it is secondary to protracted URTI&#44; it is not serious and resolves spontaneously&#46; Sometimes persistent cough is due to an increase in sensitivity of the cough receptors after a viral infection&#44;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> but factors such as environmental contamination and exposure to tobacco smoke may be observed in this entity&#44; and may contribute to its persistence&#46;<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">33</span></a> Many of these cases are treated incorrectly with inhaled corticosteroids&#44; having been classified as &#8220;cough variant asthma&#8221;&#46;<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4&#44;34&#44;35</span></a></p></li></ul></p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Diagnostic Evaluation of Chronic Cough</span><p id="par0065" class="elsevierStylePara elsevierViewall">The time and evolution&#44; type of cough&#44; diurnal pattern&#44; aggravating factors and triggers&#44; quality of the cough &#40;dry or productive&#41; and associated symptoms should be evaluated from the <span class="elsevierStyleItalic">clinical records</span><a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4&#44;36&#44;37</span></a> &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41;&#46; It is essential that the characteristics of the cough&#44; whether dry or productive&#44; are evaluated&#44; since productive&#44; purulent chronic cough is pathological and requires investigation for suppurative diseases&#46; If cough is accompanied by wheezing or breathing difficulties&#44; the spectrum of possible etiological causes is wide&#58; asthma&#44; foreign body&#44; recurrent aspirations&#44; tracheobronchomalacia&#44; bronchiolitis obliterans&#44; interstitial diseases&#44; chronic pulmonary disease in pre-term infants and heart diseases&#44; among others&#46; When it is associated with atopic dermatitis&#44; allergic rhinitis or sensitivity to allergens&#44; personal and family history of allergy or asthma&#44; occurs at night and is exacerbated with exercise&#44; cold or exposure to irritants or allergens&#44; a diagnosis of asthma is more probable&#46;<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">35</span></a> If hemoptysis is observed&#44; pneumonia&#44; pulmonary abscesses&#44; BE&#44; CF&#44; foreign bodies&#44; tuberculosis&#44; pulmonary hemosiderosis&#44; tumors&#44; pulmonary hypertension or pulmonary arteriovenous malformations must be excluded&#46; Nasal obstruction&#44; mucopurulent rhinorrhea and halitosis would suggest upper airway cough syndrome or posterior nasal drip&#46;<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">38</span></a> Persistent headache may be a symptom of sinusitis&#46;<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">39</span></a> Recurrent febrile syndrome&#44; general malaise&#44; constitutional symptoms and a generally productive cough would indicate the need for a contact study to rule out tuberculosis&#46;<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">40</span></a> In aspirative syndromes&#44; cough is generally associated with food-related regurgitation and choking&#46;<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">41</span></a> Psychogenic cough is dry&#44; hacking&#44; repetitive and frequent during the day&#44; and calms down or disappears during sleep&#59; it is exacerbated in the presence of parents or caregivers and diminishes with distraction and sport&#46; It is diagnosed exclusively in a healthy child who does not improve with medication&#46;<a class="elsevierStyleCrossRefs" href="#bib0095"><span class="elsevierStyleSup">19&#44;20</span></a> Finally&#44; to guide diagnosis&#44; it is always important to determine if the patient has received any type of treatment and what effect it has had on the cough&#44; to enquire about environmental factors &#40;smoking in the family&#44; daycare attendance&#44; animals&#44; environmental irritants&#44; etc&#46;&#41; and to look for alarm signs or symptoms &#40;neonatal onset&#44; cough during feeding&#44; cough with sudden onset&#44; suppurative cough with expectoration&#44; nocturnal sweating&#44; associated weight loss or signs of chronic pulmonary disease&#44; etc&#46;&#41;&#46; Alarm signs and symptoms in the study of children with chronic cough are listed in <a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><p id="par0070" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Physical examination</span> must be complete and detailed&#44; including the ear&#44; nose and throat&#46; <span class="elsevierStyleItalic">Diagnostic tests</span> should be requested after a full history and clinical examination have been obtained&#46;<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">10&#44;15</span></a> Chest X-ray is the first study<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">12&#44;13&#44;36</span></a> and&#44; depending on the results&#44; the following tests should be considered &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#46;<ul class="elsevierStyleList" id="lis0010"><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">a&#46;</span><p id="par0075" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Laboratory tests&#58;</span> full blood panel with immunoglobulins&#44; in case of suspected immunodeficiencies in children with cough and recurrent bacterial infections&#46;<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">36</span></a></p></li><li class="elsevierStyleListItem" id="lsti0025"><span class="elsevierStyleLabel">b&#46;</span><p id="par0080" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Skin tests&#58;</span> tuberculin sensitivity test&#44; sweat test &#40;electrolytes in sweat with determination of chloride&#41; and allergy study&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a></p></li><li class="elsevierStyleListItem" id="lsti0030"><span class="elsevierStyleLabel">c&#46;</span><p id="par0085" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Microbiological study&#58;</span> sputum or nasopharyngeal aspirate culture for study of respiratory viruses&#44; bacterial cultures and&#47;or cellularity studies&#46;<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">12&#8211;14</span></a></p></li><li class="elsevierStyleListItem" id="lsti0035"><span class="elsevierStyleLabel">d&#46;</span><p id="par0090" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Other radiological studies&#58;</span> chest X-ray in inspiration and expiration in case of suspected foreign body&#46; High-resolution computed axial tomography for suspected suppurative diseases&#44; pulmonary malformations or severe infections&#46; Upper gastrointestinal transit &#40;UGT&#41; for suspected foreign bodies in the esophagus&#44; tracheoesophageal fistulas and extrinsic compressions&#46;<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">12&#8211;14</span></a></p></li><li class="elsevierStyleListItem" id="lsti0040"><span class="elsevierStyleLabel">e&#46;</span><p id="par0095" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Pulmonary function&#58;</span> spirometry can be carried out from the age of 3&#8211;4 years with appropriate training&#46; A positive bronchodilator test suggests asthma&#44; but to reach a diagnosis&#44; complementary studies &#40;metacholine&#44; exhaled nitric oxide or induced sputum&#41; are required when it is normal&#46;<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">13&#44;42</span></a></p></li><li class="elsevierStyleListItem" id="lsti0045"><span class="elsevierStyleLabel">f&#46;</span><p id="par0100" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Fiberoptic bronchoscopy&#58;</span> this should be performed in all children with chronic cough and suspicion of airway abnormalities&#44; foreign body inhalation&#44; aspirations&#44; if localized radiological changes are observed or for performing bronchoalveolar lavage and microbiological studies&#46;<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">12&#44;13&#44;39</span></a></p></li><li class="elsevierStyleListItem" id="lsti0050"><span class="elsevierStyleLabel">g&#46;</span><p id="par0105" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">pH monitoring&#58;</span> this should be performed if GERD is suspected&#44; even though normal results do not exclude the presence of non-acid reflux&#44; which should be evaluated with impedance testing&#46;<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">13&#44;38&#44;43</span></a></p></li></ul></p><elsevierMultimedia ident="fig0010"></elsevierMultimedia></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Most Common Diagnoses of Chronic Cough in Children</span><p id="par0110" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Asthma</span>&#46; Children with asthma can begin with cough&#44; but most children with non-specific cough do not have asthma&#46;<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">44</span></a> Recurrent dry cough may be due to increased sensitivity of cough receptors&#44;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> frequently caused by URTI&#46; BHR is associated with wheezing but not with persistent dry cough or nocturnal cough&#46;<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">45</span></a> Risk factors&#44; the characteristics of the cough&#44; presence of wheezing and spirometry can assist in reaching a diagnosis&#46;<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">13&#44;14&#44;35&#44;42</span></a></p><p id="par0115" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Persistent Bacterial Bronchitis</span>&#46; Until recently&#44; persistent bacterial bronchitis was understudied and underdiagnosed&#46; It is defined as productive chronic cough secondary to airway infection that resolves with long-term antibiotic treatment&#44; after other diseases have been ruled out&#46;<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">46</span></a> The most commonly involved microorganisms are <span class="elsevierStyleItalic">Streptococcus pneumoniae</span>&#44; <span class="elsevierStyleItalic">Haemophilus influenzae</span> and <span class="elsevierStyleItalic">Moraxella catarrhalis</span>&#44; and in some cases&#44; more than one pathogen is isolated&#46;<a class="elsevierStyleCrossRefs" href="#bib0145"><span class="elsevierStyleSup">29&#44;47</span></a> Definitive diagnosis is carried out by bronchoscopy and bronchoalveolar lavage&#44; but administration of antibiotics for 2&#8211;4 weeks can be tried to see if the clinical picture resolves before carrying out a bronchoscopy&#46; Some patients with recurrent PBB require long and repeated cycles of antibiotics&#44; for which reason some authors propose the possibility of long-term treatment with inhaled antibiotics&#46;<a class="elsevierStyleCrossRef" href="#bib0240"><span class="elsevierStyleSup">48</span></a> This is a disease entity that may be associated with asthma and involves a high level of morbidity&#44; so it should be diagnosed and treated appropriately to avoid it progressing to BE&#46;</p><p id="par0120" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Upper Airway Cough Syndrome or Posterior Nasal Drip</span>&#46; This is one of the main causes of chronic cough in adults&#44; but it is less common in the pediatric population&#46;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a> It is due to mechanical stimulation of the afferent branch of the cough reflex in the upper airway by secretions that descend from the nose and&#47;or the paranasal sinuses&#46; In preschoolers&#44; it is caused by repeated infections due to adenotonsillar hypertrophy and&#47;or seromucous otitis&#46; In schoolchildren&#44; persistent rhinitis and&#47;or turbinate hypertrophy should suggest atopy&#44; and if nasal polyps are observed&#44; CF should be ruled out&#46;<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#44;49</span></a></p><p id="par0125" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Gastroesophageal Reflux Disease</span>&#46; The association between GERD and non-specific chronic cough in children is widely debated&#44; since there is little evidence that this disease alone causes cough&#46;<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">32</span></a> For the determination of acid GERD&#44; 24-h pH testing is sensitive and specific&#44; while impedance is required for the diagnosis of non-acid GERD&#46;<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">30</span></a> UGT assists in the diagnosis of vascular rings and other causes of mechanical compression&#46;<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">12&#8211;14</span></a></p><p id="par0130" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Functional Respiratory Disorders</span>&#46; It is important to recognize psychogenic cough and other functional respiratory disorders in pediatric patients&#44; since they are difficult to diagnose and are frequently labeled as asthma or upper airway cough syndrome&#46; Psychogenic cough is less common in males&#44; and generally occurs in schoolchildren or teenagers who&#44; after a URTI&#44; begin with a dry&#44; harsh&#44; croaking cough that occurs intermittently during the day but then disappears when the subject is distracted or sleeping&#46; It is generally very alarming for parents&#44; teachers and others to observe&#44; but the patient is usually surprisingly indifferent&#46;<a class="elsevierStyleCrossRefs" href="#bib0095"><span class="elsevierStyleSup">19&#44;20</span></a></p></span><span id="sec0080" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Treatment of Chronic Cough in Children</span><p id="par0135" class="elsevierStylePara elsevierViewall">Chronic cough should be treated after a thorough etiological study&#44; the aim being to eliminate the causative agent&#44; following clinical practice guidelines&#46;<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">12&#8211;14</span></a> The family must be reminded to avoid exposing the child to tobacco smoke and other environmental irritants&#46;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a></p><p id="par0140" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Treatment of Specific Cough</span>&#46; Chronic cough due to asthma requires treatment with bronchodilators and&#44; depending on classification&#44; with inhaled corticosteroids&#46;<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">42</span></a> In cases of allergic rhinitis&#44; antihistamines and nasal steroids will be required&#46;<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">38</span></a> Sinusitis will require treatment with antibiotics&#46;<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">39</span></a> GERD should be treated with proton pump inhibitors and&#47;or surgery&#46;<a class="elsevierStyleCrossRef" href="#bib0250"><span class="elsevierStyleSup">50</span></a> PBB needs long-term treatment &#40;between 2 and 6 weeks&#41; with amoxicillin&#8211;clavulanate or clarithromycin&#46;<a class="elsevierStyleCrossRefs" href="#bib0145"><span class="elsevierStyleSup">29&#44;46&#8211;48</span></a> Psychogenic cough requires investigation of the causes of stress or anxiety and subsequent psychological support&#46;<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">12&#8211;14&#44;19&#44;20</span></a></p><p id="par0145" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Treatment of Non-specific Cough</span>&#46; If the cough has a moderate impact&#44; there is no underlying disease and the child is healthy&#44; a period of observation is recommended before diagnostic tests or treatment are initiated&#44; with a follow-up examination of the child after 6&#8211;8 weeks&#46; If a decision is taken to carry out a trial treatment&#44; the duration should be empiric and based on the recommendations of experts&#44; given the lack of controlled studies in the pediatric population&#46;<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4&#44;12&#44;16</span></a> A trial treatment with inhaled corticosteroids at half doses is recommended for predominantly dry cough &#40;budesonide 400<span class="elsevierStyleHsp" style=""></span>&#956;g&#47;day or equivalent&#41; for 2&#8211;12 weeks&#44; depending on the guidelines&#46; The patient should be reassessed after 2&#8211;3 weeks and if there has been no response to treatment&#44; it should be discontinued<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">12&#44;13</span></a> &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>&#41;&#46; In cases of non-specific productive cough&#44; initiating a course of antibiotics &#40;amoxicillin&#8211;clavulanate&#41; for 2&#8211;3 weeks may be considered&#46; Chang et al&#46;<a class="elsevierStyleCrossRef" href="#bib0255"><span class="elsevierStyleSup">51</span></a> carried out a study in children with cough of more than 4 weeks&#8217; duration&#44; who were randomized to follow a previously defined treatment algorithm after 4 weeks or to continue the untreated observation period for 6&#8211;8 weeks&#46; The primary endpoint of the study was resolution of cough at 6 weeks&#46; The duration of cough was shorter in the early treatment group&#46; In some patients&#44; cough resolves spontaneously&#44; irrespective of treatment&#44; and the diagnosis of cough as &#8220;cough variant asthma&#8221; can only be established if symptoms recur after treatment withdrawal and respond again after it is reintroduced&#44; so a positive response with inhaled corticosteroids does not confirm the diagnosis of asthma&#46; The use of central action antitussives&#44; non-opiate antitussives&#44; mucolytics or expectorants is not indicated&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> The presence of more than one cause of cough may lead to a delay in response or treatment failure if underlying conditions are not treated&#46;</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia></span></span></span><span id="sec0095" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Conclusions</span><p id="par0150" class="elsevierStylePara elsevierViewall">Cough in childhood is a common symptom that&#44; in most cases&#44; is due to banal respiratory infections&#44; but all children with chronic cough must be thoroughly studied to determine the underlying cause&#46; Detailed history and physical examinations&#44; with chest X-ray and spirometry &#40;if possible&#41; are recommended&#46; Specific chronic cough should be treated according to the underlying disease&#46; If diagnosis is unclear&#44; the characteristics of the cough&#44; whether dry or productive&#44; can help in evaluating possible treatment&#58; inhaled corticosteroids for dry cough or antibiotics for productive cough&#46; If no improvement is observed&#44; these treatments should be discontinued and alternative diagnoses explored&#44; bearing in mind that in some cases the cause of cough may be more than one disease&#46; There is no evidence that the use of antitussive syrups and&#47;or antihistamines or other cough remedies are effective&#44; and&#44; with the exception of honey for URTI&#44; they may have serious adverse effects in children&#44; so they must not be used&#46;</p></span><span id="sec0100" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Funding</span><p id="par0155" class="elsevierStylePara elsevierViewall">This review was conducted without funding&#46;</p></span><span id="sec0105" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Conflict of Interests</span><p id="par0160" class="elsevierStylePara elsevierViewall">The authors state that they have no conflict of interest&#46;</p></span></span>"
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          "titulo" => "Abstract"
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        1 => array:2 [
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          "titulo" => "Keywords"
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        2 => array:2 [
          "identificador" => "xres349275"
          "titulo" => "Resumen"
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          "identificador" => "xpalclavsec330938"
          "titulo" => "Palabras clave"
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          "identificador" => "sec0005"
          "titulo" => "Introduction"
        ]
        5 => array:2 [
          "identificador" => "sec0010"
          "titulo" => "Etiology of Cough in Children"
        ]
        6 => array:3 [
          "identificador" => "sec0015"
          "titulo" => "Evaluation of the Child With Cough"
          "secciones" => array:3 [
            0 => array:3 [
              "identificador" => "sec0020"
              "titulo" => "Acute Cough"
              "secciones" => array:2 [
                0 => array:2 [
                  "identificador" => "sec0025"
                  "titulo" => "Diagnostic Evaluation of Acute Cough"
                ]
                1 => array:2 [
                  "identificador" => "sec0030"
                  "titulo" => "Treatment of Acute Cough"
                ]
              ]
            ]
            1 => array:2 [
              "identificador" => "sec0035"
              "titulo" => "Subacute Cough"
            ]
            2 => array:3 [
              "identificador" => "sec0040"
              "titulo" => "Chronic Cough"
              "secciones" => array:3 [
                0 => array:2 [
                  "identificador" => "sec0045"
                  "titulo" => "Diagnostic Evaluation of Chronic Cough"
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                1 => array:2 [
                  "identificador" => "sec0050"
                  "titulo" => "Most Common Diagnoses of Chronic Cough in Children"
                ]
                2 => array:2 [
                  "identificador" => "sec0080"
                  "titulo" => "Treatment of Chronic Cough in Children"
                ]
              ]
            ]
          ]
        ]
        7 => array:2 [
          "identificador" => "sec0095"
          "titulo" => "Conclusions"
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        8 => array:2 [
          "identificador" => "sec0100"
          "titulo" => "Funding"
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        9 => array:2 [
          "identificador" => "sec0105"
          "titulo" => "Conflict of Interests"
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        10 => array:1 [
          "titulo" => "References"
        ]
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    "tienePdf" => true
    "fechaRecibido" => "2013-04-19"
    "fechaAceptado" => "2013-09-19"
    "PalabrasClave" => array:2 [
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        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Keywords"
          "identificador" => "xpalclavsec330937"
          "palabras" => array:5 [
            0 => "Cough"
            1 => "Children"
            2 => "Protracted bacterial bronchitis"
            3 => "Asthma"
            4 => "Gastrooesophageal reflux"
          ]
        ]
      ]
      "es" => array:1 [
        0 => array:4 [
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          "titulo" => "Palabras clave"
          "identificador" => "xpalclavsec330938"
          "palabras" => array:5 [
            0 => "Tos"
            1 => "Ni&#241;os"
            2 => "Bronquitis bacteriana persistente"
            3 => "Asma"
            4 => "Reflujo gastroesof&#225;gico"
          ]
        ]
      ]
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    "resumen" => array:2 [
      "en" => array:2 [
        "titulo" => "Abstract"
        "resumen" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Cough during childhood is very common&#44; and is one of the most frequent reasons for consultation in daily pediatric practice&#46; The causes differ from those in adults&#44; and specific pediatric guidelines should be followed for correct diagnosis and treatment&#46; The most common cause of cough in children is viral infection producing &#8220;normal cough&#8221;&#44; but all children with persistent cough&#44; i&#46;e&#46; a cough lasting more than 4&#8211;8<span class="elsevierStyleHsp" style=""></span>weeks or &#8220;chronic cough&#8221;&#44; must be carefully evaluated in other to rule out specific causes that may include the entire pediatric pulmonology spectrum&#46; The treatment of cough should be based on the etiology&#46; Around 80&#37; of cases can be diagnosed using an optimal approach&#44; and treatment will be effective in 90&#37; of them&#46; In some cases of &#8220;nonspecific chronic cough&#8221;&#44; in which no underlying condition can be found&#44; empirical treatment based on the cough characteristics may be useful&#46; There is no scientific evidence to justify the use of over-the-counter cough remedies &#40;anti-tussives&#44; mucolytics and&#47;or antihistamines&#41;&#44; as they could have potentially serious side effects&#44; and thus should not be prescribed in children&#46;</p>"
      ]
      "es" => array:2 [
        "titulo" => "Resumen"
        "resumen" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">La tos en la infancia es un s&#237;ntoma muy frecuente&#44; y constituye uno de los motivos de consulta m&#225;s comunes en la pr&#225;ctica pedi&#225;trica diaria&#46; Las causas de tos en el ni&#241;o son diferentes a las del adulto y se deben seguir las gu&#237;as espec&#237;ficas de la edad pedi&#225;trica para su diagn&#243;stico y tratamiento&#46; En la mayor&#237;a de casos la causa son infecciones respiratorias banales que producen una &#171;tos normal o esperada&#187;&#44; pero todo ni&#241;o con tos que persiste m&#225;s all&#225; de las 4 a 8<span class="elsevierStyleHsp" style=""></span>semanas se considera que tiene &#171;tos cr&#243;nica&#187; y debe ser evaluado para descartar patolog&#237;as espec&#237;ficas que abarcan todo el espectro de la neumolog&#237;a pedi&#225;trica&#46; El tratamiento de la tos debe realizarse en funci&#243;n de la etiolog&#237;a&#46; Con un abordaje adecuado se puede identificar la misma hasta en el 80&#37; de los casos y el tratamiento ser&#225; efectivo en el 90&#37; de ellos&#46; En algunos casos de &#171;tos cr&#243;nica inespec&#237;fica&#187;&#44; tos en la que se ha descartado patolog&#237;a subyacente&#44; se puede realizar un tratamiento emp&#237;rico en funci&#243;n de las caracter&#237;sticas de la tos&#46; No hay evidencia cient&#237;fica que justifique el empleo de tratamientos sintom&#225;ticos que alivien la tos&#44; como jarabes antitusivos&#44; mucol&#237;ticos y&#47;o antihistam&#237;nicos&#44; ya que pueden tener efectos secundarios potencialmente graves&#44; por lo que no se deben emplear&#46;</p>"
      ]
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    "NotaPie" => array:1 [
      0 => array:2 [
        "etiqueta" => "&#9734;"
        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Lamas A&#44; Ruiz de Valbuena M&#44; M&#225;iz L&#46; Tos en el ni&#241;o&#46; Arch Bronconeumol&#46; 2014&#59;50&#58;294&#8211;300&#46;</p>"
      ]
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        "fuente" => "Taken from Chang AB&#46; Causes&#44; assessment and measurements in children&#46; In&#58; Chung FK&#44; Widdicombe JG&#44; Boushey HA&#44; editors&#46; Cough&#58; causes&#44; mechanisms and therapy&#46; London UK&#58; Blackwell Science&#59; 2003&#58;57&#8211;73&#46;"
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          "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Classification of chronic cough by etiology&#46;</p>"
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        "etiqueta" => "Fig&#46; 2"
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        "mostrarFloat" => true
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        "fuente" => "Taken from Saranz R&#46; Diagn&#243;stico y tratamiento de la tos cr&#243;nica en pediatr&#237;a&#46; Arch Argent Pediatr&#46; 2013&#59;111&#58;140&#8211;47&#46;"
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          "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Diagnostic algorithm of chronic cough in children&#46;</p>"
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          "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Chronic non-specific cough treatment algorithm&#46; IC&#58; inhaled corticosteroids&#46;</p>"
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          "leyenda" => "<p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">BE&#58; bronchiectasis&#59; <span class="elsevierStyleItalic">C&#46; trachomatis</span>&#58; <span class="elsevierStyleItalic">Chlamydia trachomatis</span>&#59; PCD&#58; primary ciliary dyskinesia&#59; CF&#58; cystic fibrosis&#59; <span class="elsevierStyleItalic">M&#46; pneumoniae</span>&#58; <span class="elsevierStyleItalic">Mycoplasma pneumoniae</span>&#46;</p>"
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                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Chronic cough in healthy children&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Chronic cough in children with pulmonary disease&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">Repeated respiratory infections&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Suppurative diseases&#58; CF&#44; BE or PCD&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Persistent bacterial bronchitis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Immunodeficiencies&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Upper airway cough syndrome or post-nasal drip&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Aspirative syndromes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Cough-variant asthma&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Aspiration of foreign body&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Psychogenic cough&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Infections&#58; <span class="elsevierStyleItalic">Mycoplasma pneumoniae</span>&#44; <span class="elsevierStyleItalic">Chlamydia trachomatis</span>&#44; tuberculosis&#44; pneumonia&#44; etc&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Irritative cough &#40;tobacco or other irritants&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Congenital abnormalities&#58; trachoesophageal fistula&#44; vascular rings&#44; airway malformations&#44; neuromuscular diseases&#44; etc&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
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        "descripcion" => array:1 [
          "en" => "<p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Differential Diagnosis of Specific Causes of Chronic Cough in Children&#46;</p>"
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        "tabla" => array:2 [
          "leyenda" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">PBB&#58; persistent bacterial bronchitis&#59; BE&#58; bronchiectasis&#59; PCD&#58; primary ciliary dyskinesia&#59; CF&#58; cystic fibrosis&#59; ENT&#58; ear&#44; nose&#44; throat&#59; TB&#58; tuberculosis&#59; HIV&#58; human immunodeficiency virus&#46;</p>"
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                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t" style="border-bottom: 2px solid black">Clinical history&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t" style="border-bottom: 2px solid black">Remarks&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Nature of the cough</span></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Severity&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">Rule out potentially serious specific diseases&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Time of appearance&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Causes of cough vary with age&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Diurnal variability&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Nocturnal cough is more common with asthma or rhinitis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Sputum production&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Evaluate suppurative diseases&#58; CF&#44; BE&#44; PCD&#44; PBB&#44; etc&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Associated wheezing&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Evaluate asthma&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Appearance or non-appearance of cough during sleep&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Psychogenic cough does not generally appear during sleep&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Hemoptysis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Suppurative diseases&#44; malformations&#44; bronchitis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Time since onset</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Allows cough to be classified as acute&#44; subacute and chronic&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Type of cough</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Metallic&#44; hacking&#44; dry&#44; spasmodic&#44; staccato&#44; paroxystic&#44; etc&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Age at onset</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Neonatal onset&#59; congenital malformations or neuromuscular diseases&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Relation with feeding or swallowing</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Possible aspirative syndrome&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Fever</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Exclude infectious disease&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Contact with TB and or HIV</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Exclude these diseases&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Chronic symptoms of ENT disease</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Evaluate the possibility of PCD&#44; chronic ENT diseases&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Aspiration of foreign body</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Consider always in case of sudden onset cough&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Improvement of clinical symptoms with medication</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Evaluate improvement after administration of bronchodilators or antibiotics&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Exposure to tobacco smoke</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Evaluate if failure to resolve or protracted resolution&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Triggering factors</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Cold&#44; temperature changes&#44; exercise&#44; exposure to allergens&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Immunological status and recurrent infectious disease</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Evaluate the possibility of immunodeficiencies&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Drug use</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Evaluate the possibility of treatment with angiotensin converting enzyme inhibitors or others&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">History of atopy or chronic diseases</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Possibility of asthma&#44; CT&#44; PCD&#44; BE&#44; etc&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Growth and development</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Evaluate immunodeficiencies&#44; congenital diseases&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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          "en" => "<p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Key Points in the Clinical History of the Child With Chronic Cough&#46;</p>"
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        "tabla" => array:2 [
          "leyenda" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">PBB&#58; persistent bacterial bronchitis&#59; BE&#58; bronchiectasis&#59; PCD&#58; primary ciliary dyskinesia&#59; CF&#58; cystic fibrosis&#46;</p>"
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Alarm signs and symptoms&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Remarks&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Abnormal auscultation&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Asthma&#44; bronchitis&#44; foreign body&#44; CF&#44; congenital abnormalities&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Productive cough&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Suppurative diseases &#40;CF&#44; BE&#44; PCD&#44; PBB&#44; etc&#46;&#41;&#44; bronchitis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Sudden onset of cough after episode of choking&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Aspiration of foreign body&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Cough associated with food or swallowing&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Aspirative syndromes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Chronic dyspnea&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Chest disease &#40;airway or parenchyma&#41;&#44; heart disease&#44; etc&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Dyspnea with exercise&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Asthma&#44; pulmonary disease&#44; etc&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Heart murmur&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Heart disease&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Neurological disease&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Expirative syndromes&#44; muscle weakness&#44; etc&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Chest wall deformities&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Malformations&#44; severe chronic pulmonary disease&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Hemoptysis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Suppurative disease&#44; vascular abnormalities&#44; malformations&#44; etc&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Recurrent pneumonia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Asthma&#44; foreign body&#44; malformations&#44; immunodeficiencies&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Failure to thrive&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Pulmonary or heart disease&#44; etc&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Acropachy&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Pulmonary disease&#44; suppurative disease&#44; heart disease&#44; etc&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Comorbidities&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Chronic diseases&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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          "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Alarm Signs and Symptoms in Children With Chronic Cough&#46;</p>"
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      ]
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Article information

ISSN: 15792129
Original language: English

DOI:10.1016/j.arbr.2014.05.002

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Year/Month	Html	Pdf	Total

2024 November	9	10	19
2024 October	172	145	317
2024 September	229	103	332
2024 August	226	110	336
2024 July	174	85	259
2024 June	174	129	303
2024 May	232	74	306
2024 April	155	98	253
2024 March	156	83	239
2024 February	108	71	179
2024 January	1	0	1
2023 March	36	23	59
2023 February	173	204	377
2023 January	128	145	273
2022 December	136	200	336
2022 November	171	166	337
2022 October	150	184	334
2022 September	88	189	277
2022 August	137	149	286
2022 July	117	195	312
2022 June	114	150	264
2022 May	117	200	317
2022 April	156	162	318
2022 March	170	283	453
2022 February	111	242	353
2022 January	126	274	400
2021 December	101	161	262
2021 November	138	169	307
2021 October	128	165	293
2021 September	104	154	258
2021 August	104	162	266
2021 July	96	131	227
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2021 April	606	567	1173
2021 March	265	299	564
2021 February	186	248	434
2021 January	120	169	289
2020 December	128	255	383
2020 November	137	182	319
2020 October	137	206	343
2020 September	131	114	245
2020 August	90	96	186
2020 July	108	78	186
2020 June	216	89	305
2020 May	179	136	315
2020 April	283	230	513
2020 March	292	180	472
2020 February	240	199	439
2020 January	205	164	369
2019 December	243	175	418
2019 November	307	172	479
2019 October	435	173	608
2019 September	185	121	306
2019 August	141	100	241
2019 July	199	82	281
2019 June	135	94	229
2019 May	170	99	269
2019 April	225	154	379
2019 March	252	180	432
2019 February	135	107	242
2019 January	145	87	232
2018 December	139	92	231
2018 November	334	119	453
2018 October	529	101	630
2018 September	166	89	255
2018 August	1	0	1
2018 June	3	0	3
2018 May	54	9	63
2018 April	183	119	302
2018 March	194	93	287
2018 February	82	118	200
2018 January	105	81	186
2017 December	102	84	186
2017 November	106	99	205
2017 October	77	130	207
2017 September	109	105	214
2017 August	86	87	173
2017 July	89	135	224
2017 June	122	107	229
2017 May	139	106	245
2017 April	92	95	187
2017 March	85	151	236
2017 February	63	106	169
2017 January	61	63	124
2016 December	105	52	157
2016 November	137	84	221
2016 October	195	126	321
2016 September	231	94	325
2016 August	219	67	286
2016 July	89	40	129
2016 June	2	0	2
2016 March	2	0	2
2016 February	2	0	2
2015 December	3	0	3
2015 October	105	12	117
2015 September	113	25	138
2015 August	111	30	141
2015 July	140	27	167
2015 June	94	17	111
2015 May	103	34	137
2015 April	107	35	142
2015 March	96	22	118
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2015 January	81	25	106
2014 December	56	23	79
2014 November	58	18	76
2014 October	61	24	85
2014 September	1	0	1
2014 August	0	1	1
2014 July	1	1	2

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