Cough: Post-Viral

Cough is one of the most distressing symptoms in children. It sounds painful, it keeps a child awake, and it often bothers other people. Some children just can’t seem to shake a cough no matter what we do. In children with a persistent cough who do not have asthma, the most common cause of the cough seems to be that it follows a recent cold or upper respiratory infection (URI). Since viruses cause these conditions, we call this kind of cough a "post-viral" cough. Doctors diagnose a post-viral cough when they are fairly sure there is no other, more obvious cause, such as asthma, cough-variant asthma, pneumonia, stomach reflux, or allergies. Most doctors and researchers believe that the cause of a post-viral cough is irritation of the nose and throat that outlasts the original viral infection. This irritation can produce a slow dripping of mucous from the back of the nose into the throat ("post-nasal drip") that is often worse when the child lies down. The irritation also can be part of a vicious cycle – the irritation causes the child to cough, and the frequent coughing causes more irritation, and so forth.

The biggest concern is the child’s comfort and rest. Any persistent cough is both painful and distracting for a child. Cough can also decrease a child’s appetite. Cough that is worse at night can interfere with a child’s sleep pattern. It can also disrupt parents’ sleep, making them miss work or other daytime activities. It is also important, of course, to make certain that we have ruled out some of the other more dangerous causes of coughing, like those we mentioned above. Once those have been ruled out, we can treat the symptoms of the cough, and the child’s discomfort, more readily.

Most of the time doctors prefer not to treat post-viral cough with medications. There are no medications to kill the virus, and many of the over-the-counter and prescription cough medicines contain ingredients that can harm children. Some of these ingredients make children jittery or fussy, and most make their hearts beat fast and give them dry mouths. Because a cough is often a protective reflex to keep a more serious lung infection from developing, many doctors prefer to try to "wait out" the irritation that causes the cough. Some non-medication steps can help to break the vicious cycle of cough-irritation-cough. Some things you can do to help include:

• Using a humidifier or vaporizer in your child’s room. Please remember to change the water daily to prevent mold and mildew from growing in it
• Increasing oral fluids that are not high in sugar content
• Avoid exposing the child to smoke of any kind. If smokers live in the house where your child lives, this can be next to impossible. Now is not the time to try to convince yourself or someone else to quit smoking – but it’s a great time to make plans to quit. You can read our Aftercare Instructions on Smoking Cessation. Meanwhile, if there’s a non-smoking relative or friend where the child can safely stay for at least a few days, that might help.
• Have your child take several warm baths or showers a day to keep the membranes in his or her nose and throat moist.
• Try a topical spray such as Chloraseptic® just before bed-time, if your child will tolerate it. This can relieve some of the irritation and is safe to use as often as every 2 hours. Chloraseptic®, Cepacol®, or other "medicated" throat lozenges may help too. Please use lozenges or cough drops only in children older than 8 years old, because of the risk of choking. Even in older children, please make sure your child has finished the lozenge before putting him or her to bed.
• For children younger than 8 years, you can give a lollipop instead of a non-medicated throat lozenge. This will help increase saliva production and soothe the throat, though it only works while the lollipop is being used. Be sure to have your child brush his or her teeth after using cough drops or lollipops.

If these "non-medication" steps don’t help after several days, you and your doctor may want to try a different strategy. Many doctors will prescribe a short course of an asthma inhaler at this point, to see if perhaps the child has "cough variant asthma." If the child improves, the diagnosis is clear. If the child does not improve, we have to try something else. At this point (if not sooner), many doctors do recommend using a simple cough syrup that contains the ingredient "guaifenesin" (gwy-fenn-iss-en). This medication is very safe and is meant to help loosen secretions so that the child can bring them up. Researchers are divided in their opinions about how well guaifenesin works, but we know it is safe and if it seems to help your child, by all means continue to use it.

A persistent post-viral cough that does not clear up after trying all of these other things is one that many doctors agree might need an actual anti-cough medication (an "anti-tussive"). Codeine is one such medication. It is a mild narcotic, that is not likely to cause bad side effects if you use it as directed for a short period (not more than 3-5 days). Codeine does frequently cause constipation, so be prepared! A drug called "dextromethorphan," (dex-trow-meth-or-fan), or "DM" is related to codeine but has no narcotic effects. Both codeine and DM have proven safety records. Some doctors believe that one is better than the other – the evidence is mixed. If your doctor prescribes either one, please use it exactly as directed. Doctors usually use these medicines for a short period, to try to break the "cough-irritation-cough" cycle. Please continue to use other non-medical strategies, such as humidifiers, etc, while your child takes these medications.

Most children with post-viral cough do not have significant fever. If your child develops a fever, please call your doctor. You can use acetaminophen (Tylenol®) or ibuprofen (Advil® or Motrin®) to control fever in children over 3 months. Check with your doctor about using it in younger babies. Fever is not dangerous, but it can make the child uncomfortable. If your child seems comfortable there is no reason to give any medication just for fever.

Post-viral cough is not dangerous, assuming that all the other causes have been ruled out. Here are a few things to look for that might suggest there is something more concerning going on:

• A return of fever after the original viral infection has cleared up
• Pain in the chest when the child is not actually coughing
• A sound of wheezing (whistling noise when the child breathes out)
• A raspy, hoarse, or "barky" cough (could indicate croup, which sounds like this)
• Coughing spasms that cause the child to turn blue or pale, or cause the child to vomit at the end of the spasm
• Pulling in the skin over the ribs, breastbone or collarbones while breathing in
• Flaring nostrils
• Difficulty catching the breath, or obvious difficulty breathing

Please remember that many of the over-the-counter cough and cold medications do not work in children and can be dangerous. Some parents and doctors feel that these medicines are sometimes helpful despite recently published evidence that most are not. If you do use them, please remember that many of these medications are actually combinations of medicine. Many of them contain acetaminophen (the active ingredient in Tylenol® and others), as well as antihistamines, decongestants, and other drugs. It is important to read all the labels carefully. For example, if you give your child a cold medicine with acetaminophen in it and also give a dose of Tylenol®, you may accidentally give an overdose. Acetaminophen and other common drugs can be very dangerous in overdoses.

A coughing child can push a stressed parent right to the edge of his or her patience. It is a great idea to try to take "shifts" with your partner while your child gets over this cough, so that neither of you gets overwhelmed. If you are a single parent, or if you feel yourself nearing the breaking point, it is often a good idea to try to arrange to have another family member or trusted friend look after your child for an hour or two. This way you can get away, take care of yourself, and come back feeling just a little bit better yourself. Most children with post-viral cough can return to school or daycare with their doctor’s permission.

The diagnosis of post-viral cough is one of the most common ones we make in pediatrics and family medicine. On rare occasions, some other cause is present. An unusual, but potentially serious cause of persistent cough is pertussis, or "whooping cough." The normal childhood immunization (DTP or DTaP) shots protect most children against pertussis. Some children who get the shots don’t develop full protection, however, and some children get behind on their shots or never get them at all. Children younger than 6 months have not finished the full first set of shots, so they are at a higher risk of getting pertussis (though it is still a low risk overall). Children with pertussis typically have long coughing spasms, and they may vomit at the end of them. They may turn pale or blue during or just after the spasm. Older children (above about 3 years) make a "whooping" or rasping sound when they breathe in after the cough. Children with pertussis generally appear fairly ill, although they often do not have fever. Your doctor will test your child for pertussis if s/he is concerned about the disease, which can be treated with antibiotics.  This is what true "whooping cough" sounds like (this sound file is very painful to listen to - click to close the window if it is overwhelming).

Some children with persistent coughing have "cough variant asthma." Your doctor may have you try a short course of asthma medicine to see if this helps. You can read our Aftercare Instructions about cough variant asthma.

Having a sick child at home can be tiring and frustrating. As badly as you feel for your child, you yourself may feel out of control, inadequate, or even angry – these are normal feelings. Babies and children who are sick are often fussy and irritable, and parents often feel stressed to the breaking point, especially when there are other children or adults to take care of. One of the best things you can do for your child is to be sure you take care of yourself. If possible, try to have other adults take care of your child for an hour or two each day so you can get some rest or just some quiet time. If you get so stressed that you are worried about your baby’s safety, call your local Parents’ Anonymous Hotline or visit the Parents Anonymous website to find a group near you.