The Baby Cough that Won’t Go Away

It’s incredibly irritating to hear. It sounds uncomfortable. You can’t get past the premonition that something is terribly wrong. And, worst of all, there seems to be no end in sight.

In this day and age I could be talking about a lot of things. But in the field of infant and child medicine, the above description applies to one of the most common reasons that pediatricians see babies and young children for sick visits: that nagging, chronic cough.

Most of us can identify a cough. But what do we mean by “chronic”? As much as anything past a day or two would seem chronic at home, particularly if people have to miss work or school because of it, at least one study called it chronic if it lasted four weeks or more. For our purposes, it seems reasonable to address the reasons behind any cough that seems unremitting enough to cause a change in routine and a lot of worry.

What’s Behind All That Hack

With anything in medicine, providers try and look for signs of more concerning illness. They also want to do no harm. If a coughing child otherwise looks pretty healthy, most pediatricians would probably hone in on the most likely causes:

A string of colds. Babies get several colds a year. So do young children. The number gets less and less as one gets older, but in those first few years, especially in the winter in most climates, they can seemingly run together into one big, long cold.

One way to tell the difference between a rapid succession of colds and something else is taking a closer look at the pattern. If a child never, ever, ever has a cough-free day over several weeks, providers would more likely look for other causes. If there is even a day or two of relief from the cough, and then it starts up again, a string of colds becomes more likely.

Asthma. Asthma happens when the small airways—those tubes that go right to the lung from the windpipe (trachea) and larger airways—narrow due to certain signals from the body and/or the environment. Asthma often involves wheezing and/or obvious difficulty breathing, but in some infants and children, it shows up as a cough as its only sign.

Allergic rhinitis. This is what most people refer to as “allergies” and can involve a consistently runny and/or stuffy nose-and, yes, that cough. It’s probably not a factor in very young infants, but certainly can be one in older infants and children.

Sinus infection. While people tend to worry about this, and it does happen, a true sinus infection in infants is uncommon, simply because they don’t have a lot of sinuses! It does become more of a possibility as kids get older.

The environment. Even without a true allergy, sometimes there’s something nearby that aggravates little, sensitive noses and lungs. Most people know not to smoke in the house when there’s a baby or child, but increasing attention is being paid to “tertiary smoke”—that stuff on the clothes, and to some extent the hair and bodies, of a smoker. It appears that vaping may be worse than smoking in that regard.

Environmental woes don’t end with smoke. Sometimes a dry, dusty environment may be to blame. Or, even without a true allergy, that dust kicked up by the heater that’s suddenly on may cause symptoms.

Reflux. Sometimes a persistent cough, especially with feeding, can mean that gastroesophgeal reflux disease (GERD) is the culprit. Unlike some of the other causes we’ve mentioned, this one is something that we’d think of more in infants than older children.

There are certainly other causes, some more serious. Doctors might think about pertussis (whooping cough) if they heard the cough characteristic of that disease, if the child were unimmunized or if there were pertussis in the community. If an infant or young child might have gotten hold of a small object or even a hard piece of food, we might think about a foreign body. Other conditions, such as cystic fibrosis or a lung abnormality, generally need special testing.

Notice I’ve left out pneumonia, a common parent concern. While it sometimes does show up as a cough only (particularly if it’s due to a virus or a type of bacteria known as Mycoplasma), it’s likely to either show up with additional signs such as a fever, or findings your provider might pick up on a lung exam. For this reason, I’ve put it on the bottom of the list.

When to Worry, When Not to Worry

Let’s address the second question first. Many common signs that a young one might exhibit at home are not very specific for illness. A green runny nose can normally happen at the tail end of a regular cold. A cough that keeps a child up at night may need some attention; quite frankly, however, most coughs keep a child up at night, so that is often not helpful. Nor is the presence of “phlegm,” which can sometimes in reality be swallowed post-nasal drip.

Finally, a lot of parents are concerned because they can “hear/feel it in the chest.” There can indeed be something in the chest. However, the nose is such a good ventriloquist that I often wish that baby noses could go on tour with chests in tow and make a little money for baby’s college fund. What you’re hearing in that chest just might be transmitted nose sensation. Usually a provider can tell the difference using a stethoscope; sometimes listening over the nose in addition to the chest is necessary.

On the other hand, if you can see difficulty breathing, such as fast breathing or unusual chest movement, that’s a problem, and it’s worth quickly calling your provider. Coughs that are interfering with feeding or evidence of poor growth are also worth a call sooner rather than later. So are other signs of illness, such as a fever.

What Providers Might Do

Not a lot of testing goes into most chronic coughs. A provider might choose to do a chest x-ray, or maybe a nasal swab for pertussis, influenza (flu) or respiratory syncytial virus (RSV; this one is a cause of bronchiolitis, which is a cause of cough in young infants, but usually not a chronic cough). If GERD is suspected, the baby might be referred to a specialist. Sinus films or culturing a nose for bacteria are generally not helpful.

Many providers might choose to treat based on the symptoms and the examination. Suspected asthma might be treated with bronchodilators (medicines that open up the small airways by relaxing their muscles) and/or steroids. As much as most of us providers try to avoid unnecessary antibiotics, many (including me at times) might throw up their hands and give one a try to see if it’s helpful. Even then, however, if the cough gets better, it’s impossible to tell whether the antibiotic helped, or whether the cough would have gotten better anyway.

One group of medicines is obviously missing here: cough medicines. They’re out of favor with the medical community, particularly for children, due to the side effects and the research citing a lack of benefit. There are some honey-based preparations that can be used over the age of 1 (never in an infant due to the risk of botulism in our youngest patients), but if other medicine isn’t needed, it’s generally a matter of a little more watchful waiting and maybe the use of a vaporizer or some saline (salt water) nose drops and a bulb.

Kid coughs aren’t easy to deal with. Most of the time, no matter what we do, they’ll resolve on their own. If your child’s cough concerns you in any way, it is absolutely worth consulting with your provider. And take comfort in the fact that in most climates, as we get out of cold and flu season, they’ll generally be a lot less coughing. And that would be music to anyone’s ears.

Stan Sack
Dr. Stan Sack has 29 years’ experience as a primary care pediatrician in Massachusetts and Florida. A medical writer since 2015, he enjoys blogging on topics that are on parents’ minds but are covered less often in books and on websites. He lives in the Florida Keys with his family and enjoys healthy cooking, fitness activities and singing in his spare time.

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