Coughs in primary care Dr Nick Flynn, Medical Director, Union Quay Medical Centre and GP partner in Hollyhill Medical Centre, Cork City November is a tough month in general practice. The summer is a distant memory, the annual flu vaccination campaign is in full flight and circulating cold and flu viruses are testing capacity in daytime and out-of-hours services. November does, however, have its saving graces. There’s the Cork Film Festival, the autumn rugby internationals and for the last three years, the Irish Primary Care Respiratory Society has held its AGM in November. Normally, the meeting provides a timely reminder of the spike in respiratory presentations we see during the winter period and the most recent meeting was no different. There were presentations on asthma, asthma deaths in Ireland, COPD, and then there was Dr Reggie Spellman presenting on cough in children. Dr Spellman is the President of the Irish Primary Care Respiratory Society and throughout his career has promoted excellence in respiratory medicine in general practice. Like all good presentations, Dr Spellman’s was simple, informative and thought-provoking. All children cough at some stage. Respiratory tract infections in children are responsible for more GP consultations than any other group of illnesses. In most cases, these are self-limiting conditions and the risk of complications is small. Many children with head colds and respiratory tract infections present to their GP because of concern around the associated symptom of cough. Recommended management typically involves parental education regarding self-care and treatment of symptoms. In order to empower parents fully in this regard, we do need to inform them how long symptoms relating to a particular self-
limiting condition are likely to last. Accurate information about the expected duration of symptoms in children is essential for both parents and doctors, as it establishes parental expectations and informs them when the condition is deviating from the expected course.
Symptom duration In December 2013’s British Medical Journal, Thompson et al published a systematic review of existing literature to determine durations of symptoms of earache, sore throat, cough (including acute cough, bronchiolitis and croup), and the common cold in children. Helpfully, the authors presented their results as the number of days it took for 50 per cent and 90 per cent of the children’s symptoms to have resolved. It is reasonable to interpret these values into absolute terms as the time for half the children to get better and the time for nine-out-of-10 children to get better. This information can be used to direct more appropriate help-seeking behaviours by parents and use of antibiotics by doctors. The results showed that in 90 per cent of children, earache was resolved by seven days, sore throat resolved in two-to-seven days and acute cough resolved within three weeks (see Table 1). Acute cough had resolved in 50 per cent of children at 10 days, and in 90 per cent of children by 25 days. It would be helpful for each practice and out-of-hours co-operative to have agreed protocols on how long symptoms will last to guide help-seeking behaviour and antibiotic use (see Figure 1). The majority of children with acute cough have a viral respiratory tract infection. An attempt should be made to arrive at a specific clinical diagnosis. The absence of fever, tachypnoea and chest signs appear to be most useful indicators for ruling out future complications in children with cough in the community. Consideration should be given to potential other diagnoses, including pneumonia, an inhaled foreign body and allergy. However, acute dry cough in a well child, with a normal examination, may last up to three weeks and does not need further investigation or antibiotic treatment.
Figure 1: Proportion of children with symptoms of cough
Bronchiolitis is a common cause of acute dry cough and is the most common respiratory tract infection seen in children under one year of age. The peak incidence is between three and six months of age, occurring in particular between the months of November and May. The underlying pathophysiology is inflammation of the small airways (bronchioles). Bronchiolitis is a highly-infectious viral illness and most cases
Clinical Journal for all healthcare professionals specialising in, or with an interest in, respiratory medicine