14.3 Chronic Cough, OSA & Respiratory Red Flags
Key Takeaways
- Pediatric chronic cough is >4 weeks: sort postviral, asthma, postnasal drip, protracted bacterial bronchitis, foreign body, pertussis, CF, and GER — not an adult 8-week clock.
- CF still belongs on the list after a “normal” newborn screen: FTT, salty skin, steatorrhea, and recurrent pneumonia need a sweat chloride / CF-center workup because screening is not 100%.
- OSA is habitual snoring plus adenotonsillar hypertrophy or obesity, often with ADHD-like daytime symptoms — refer ENT/sleep rather than starting a stimulant first.
- Sudden unilateral wheeze after a choking event is an airway foreign body until proven otherwise; a normal CXR does not exclude a radiolucent object.
- Anaphylaxis, epiglottitis, and bacterial tracheitis leave the office; pulse oximetry plus work of breathing decides who goes to the ED.
After the acute viruses, clinical category #7 tests the cough that will not leave and the airway that is not safe in clinic. Chronic cough lasts more than 4 weeks in children (not the adult 8-week clock). OSA, foreign body, and the bacterial airway emergencies sit in the same differential as “another albuterol refill.”
Quick Answer: A cough >4 weeks is postviral, asthma, postnasal drip, protracted bacterial bronchitis, foreign body (unilateral), pertussis, CF (FTT, salty skin, steatorrhea, recurrent pneumonia — newborn screening is not 100%), or GER until you sort it. OSA is snoring plus adenotonsillar hypertrophy or obesity, often with ADHD-like daytime symptoms — refer ENT/sleep. Sudden unilateral wheeze is a foreign body. Anaphylaxis, epiglottitis, and bacterial tracheitis leave the office. Use pulse oximetry and send hypoxia, distress, and toxic airways to the ED.
Chronic cough: four weeks starts the workup
Ask duration, quality (wet/productive versus dry), timing (night, with exercise, after feeds, disappears in sleep), choking history, immunization (especially pertussis), growth, greasy stools, salty skin, nasal symptoms, and household smoke. Examine the nose, tonsils, chest (symmetry), and fingers (clubbing).
| Cause | Clues | First CPNP-PC move |
|---|---|---|
| Postviral / postinfectious | Improving after a documented URI; dry leftover cough | Watchful waiting if the child is well and the cough is clearly resolving; no OTC suppressants in young children |
| Asthma | Night cough, exercise, atopic history, bronchodilator response | NHLBI controller path — not months of “cough-variant” albuterol only |
| Postnasal drip / upper airway | Allergic salute, chronic rhinitis, sinus symptoms | Treat the nose; do not call every cough sinusitis |
| Protracted bacterial bronchitis (PBB) | Preschooler, wet cough >4 weeks, otherwise fairly well | Consider a 2-week course of an appropriate antibiotic (often amoxicillin-clavulanate) and follow; refer if it relapses or fails |
| Foreign body | Sudden onset, unilateral wheeze or decreased sounds, choking while eating | Urgent ENT/bronchoscopy; normal CXR does not exclude |
| Pertussis | Paroxysms, post-tussive emesis, inspiratory whoop, incomplete immunization, apnea in infants | Test and treat per public-health guidance; treat the case and close contacts as indicated |
| Cystic fibrosis | FTT, salty skin, steatorrhea, recurrent pneumonia or sinus disease, nasal polyps, clubbing | Sweat chloride / CF workup even if newborn screen was negative |
| GER | Postprandial cough, regurgitation, arching, poor weight in infants | Treat true GERD; do not PPI every chronic cough |
| Habit / somatic cough | Honking, distractible, stops in sleep | Diagnose only after organic disease is unlikely |
Cystic fibrosis is the organic miss that still appears after universal newborn screening. Screening (IRT ± DNA) is highly sensitive, not perfect. False negatives occur, especially with milder genotypes or some infants with meconium ileus. A “normal NBS” does not close the door when the phenotype is FTT, fat malabsorption, salty skin, nasal polyps, or recurrent pneumonia. Sweat chloride remains the diagnostic cornerstone; refer to a CF center. Do not keep calling that child “severe asthma.”
Pertussis still kills young infants. A vaccinated school-age sibling can be the reservoir. Infants may have apnea without a classic whoop.
Do not prescribe codeine or OTC cough and cold products to young children. Do not order a 20-allergen IgE panel as the chronic-cough workup.
OSA: snoring is a screening question, not a personality trait
Obstructive sleep apnea is repeated upper-airway obstruction in sleep. Primary-care clues:
- Habitual snoring, gasping, or witnessed pauses
- Adenotonsillar hypertrophy, mouth breathing, hyponasal speech
- Obesity
- Restless sleep, nocturnal enuresis, night sweats
- Daytime sleepiness or the pediatric twist: hyperactivity, inattention, and ADHD-like school problems
- Poor growth in some toddlers; hypertension in older children
AAP logic: screen for snoring at well visits. If the history and exam suggest OSA, refer ENT and/or sleep — do not start stimulant medication as the only plan, and do not tell the family that all snoring is benign. Polysomnography is the gold-standard diagnostic test, especially if obesity, craniofacial disease, Down syndrome, or unclear history. Adenotonsillectomy is first-line therapy for most children with OSA and adenotonsillar hypertrophy. High-risk postoperative children (age <3, severe OSA, obesity, craniofacial or neuromuscular disease) need monitored perioperative care — not a casual assumption that every community OR is equivalent.
Primary snoring without obstruction still deserves follow-up if symptoms evolve. Intranasal steroid may help selected allergic children with mild obstruction; it does not replace referral when pauses, failure to thrive, or school impairment are present.
Foreign body and the emergency airway
Airway foreign body is a history of sudden coughing or choking — peanuts, seeds, toys, latex balloons — followed by unilateral wheeze, focal decreased breath sounds, or persistent cough. Toddlers are the peak age. A normal chest x-ray does not exclude a radiolucent object. Do not start daily ICS. Do not wait for “pneumonia antibiotics to work” on a strictly unilateral, sudden story. The pathway is urgent ENT / rigid bronchoscopy. Complete obstruction is a BLS emergency (not a blind finger sweep).
Know the three toxic airway look-alikes that are not primary-care dexamethasone-and-discharge:
- Anaphylaxis: rapid urticaria, wheeze, stridor, vomiting, or hypotension after an allergen. IM epinephrine in the anterolateral thigh, then EMS (see the Allergy chapter). Albuterol is adjunct, not first-line.
- Epiglottitis: toxic, drooling, muffled voice, tripod position, little or no bark. Do not examine the throat with a tongue blade in clinic. Airway team, NPO, oxygen as tolerated, urgent ED.
- Bacterial tracheitis: toxic child, high fever, copious purulent secretions, often after viral croup that should have been improving. Needs airway support and IV antibiotics, not another steroid-only plan.
Pulse oximetry and when to send the ED
Put a pulse oximeter on any child with a respiratory complaint in clinic — cough, wheeze, stridor, pneumonia, bronchiolitis, or “just a cold” with tachypnea. A reassuring number does not override work of breathing. A low number is not a “recheck next week” plan.
Send to the ED / call EMS when:
- Hypoxia or persistent desaturation (commonly taught action threshold around <90–92% in an otherwise healthy child with distress — do not bargain an 86% toddler into a car seat for a “trial of home oxygen”)
- Moderate-severe retractions, grunting, head bobbing, inability to feed or speak
- Stridor at rest with distress, suspected epiglottitis or tracheitis
- Infant apnea, color change, or a high-risk young infant with bronchiolitis
- Anaphylaxis after epinephrine
- Suspected foreign body with ongoing symptoms
- Toxic appearance, lethargy, poor perfusion, or dehydration with respiratory disease
Mild croup after dexamethasone, well-hydrated bronchiolitis with adequate saturations, and mild CAP on amoxicillin can go home with a written worsening plan. Chronic cough in a well, saturated school-age child is an outpatient workup, not an automatic admission.
Exam traps
- Using the adult 8-week definition of chronic cough.
- Believing a negative newborn screen excludes CF.
- Treating unilateral wheeze as new asthma.
- Calling OSA “ADHD” and writing a stimulant first.
- Tongue-blading epiglottitis.
- Skipping pulse oximetry because the child is talking.
Four-week cough, CF despite NBS, ENT for OSA, bronchoscopy for unilateral sudden wheeze, epinephrine or an airway team for the toxic stridor, and a pulse ox that changes the disposition. That is the rest of pulmonology on this exam.
A 3-year-old has a 6-week wet cough, poor weight gain, greasy stools, very salty skin, and a second episode of pneumonia. The parent reports a “normal” newborn screen. Which interpretation is correct?
A 7-year-old with obesity snores nightly, has witnessed pauses, large tonsils, mouth breathing, and new daytime inattention. What is the most appropriate primary-care action?
A previously well 2-year-old had a sudden choking episode while eating peanuts and now has unilateral wheeze without fever. Oxygen saturation is 97%. What is the correct next interpretation?