complications of pneumonia, such as empyema or abscess, and in those in whom the diagnosis is in question A chest radiograph is also warranted in patients with unexplained cough, or significant or persistent pulmonary signs In children with an uncomplicated exacerbation of their asthma, a radiograph is unnecessary Inspiratory and expiratory or decubitus films have traditionally been recommended if a radiolucent foreign body is suspected; however, these studies have been found to have only fair-to-moderate sensitivity and specificity and thus their clinical utility is unknown If the suspicion for aspiration is high based on history and examination, bronchoscopy may be warranted without additional imaging beyond standard radiographs to identify radiopaque foreign bodies (see Chapter 32 Foreign Body: Ingestion and Aspiration ) All patients with hemoptysis should have chest radiographs performed Chest computed tomography is indicated in patients with persistent or moderate-to-severe hemoptysis, particularly if chest radiographs are normal Other studies that could be useful in selected patients include lateral neck radiographs, barium swallow, and computed tomography of the sinuses, neck, or chest Laboratory testing for a patient presenting to the emergency department with cough is not routinely warranted, though may be useful or necessary for specific diagnoses In the case of pneumonia, blood cultures should only be obtained in those hospitalized with moderate-to-severe disease, complicated pneumonia, failure to improve after 48 to 72 hours of antibiotic therapy, immunosuppressed patients or those with indwelling catheters with fever (see Pneumonia, Community-Acquired Pathway, https://www.chop.edu/clinicalpathway/pneumonia-community-acquired-clinical-pathway ) Additional tests for use in specific circumstances include a complete blood count and differential, tuberculin test, nasopharyngeal swab for rapid assays (commonly respiratory syncytial virus, and influenza), pertussis testing, and sputum culture and Gram stain (neutrophils and gram-positive diplococci with pneumococcal pneumonia) in those old enough to produce an adequate sample Pulmonary function testing can be useful to diagnose or follow obstructive airway disease In cases of airway masses, airway anomalies, foreign bodies, or atypical pneumonias, bronchoscopy may be necessary Approach The magnitude of a child’s respiratory distress is the most immediate concern for any child who presents with cough Any child with significant respiratory distress needs immediate attention to address their oxygenation and ventilation If not in significant distress, the next consideration is whether the onset of the cough is acute or chronic If acute in onset, the major considerations in the evaluation, as alluded to above, include the quality of the cough (e.g., paroxysmal, barking), associated stridor, associated choking or emesis, and the findings of lower respiratory tract signs or fever ( Fig 19.1 ) Most patients with cough of acute onset will have a simple URI, asthma, bronchiolitis, or pneumonia Although rales, decreased breath sounds, or focal wheezing are signs associated with pneumonia, some patients with pneumonia may not have any findings by auscultation Therefore, in cases of significant cough, especially in very young children and those with high fever or elevated white blood cell counts, a chest radiograph may be useful to exclude the diagnosis of pneumonia Children with chronic cough are likely to have reactive airway disease, allergic rhinitis, or sinusitis In young children with failure to thrive or recurrent pulmonary infections, cystic fibrosis (see Chapter 99 Pulmonary Emergencies ) should be considered Chronic cough with a history of recurrent pneumonias or chronic bronchitis can also be suggestive of immunodeficiency or anatomic lesions (see Chapters 99 Pulmonary Emergencies , 124 Thoracic Emergencies ) Choking with feeding or emesis followed by cough or wheezing in young infants is typical of gastroesophageal reflux Newborns who exhibit a cough deserve special consideration for airway anomalies, atypical pneumonias, and congestive heart failure (see Chapters 94 Infectious Disease Emergencies , 99 Pulmonary Emergencies , and 118 ENT Emergencies ) Persistent cough during the day that stops with distraction or sleep is supportive of a psychogenic cause TREATMENT The primary goal should be to treat the underlying process rather than to attempt to suppress the cough Patients with any distress or hypoxia need supplemental oxygen and immediate assessment of the airway and breathing Wheezing from asthma is primarily treated with inhaled beta-2 agonists (see Asthma, Emergent Care Pathway https://www.chop.edu/clinical-pathway/asthma-emergent-careclinical-pathway , Chapter 84 Wheezing , and Chapter 99 Pulmonary Emergencies ) The treatment for bronchiolitis is mainly supportive, including nasal suctioning, ensuring hydration, and providing supplemental oxygen as needed The 2014 American Academy of Pediatrics Clinical Practice Guideline for bronchiolitis recommends against a trial of a bronchodilator in infants with bronchiolitis However, a carefully monitored trial of a bronchodilator may be beneficial in some infants but should always be accompanied by an objective assessment of response after administration If there is no improvement, these agents should be stopped (see Bronchiolitis, Emergent Evaluation Pathway https://www.chop.edu/clinical-pathway/bronchiolitis-emergent-evaluation- clinical-pathway ) In children with suspected reactive airway disease based on history alone, a trial of bronchodilator therapy is warranted Follow-up with the primary care physician is crucial for establishing an ongoing treatment plan Children with suspected foreign bodies or airway masses (intrinsic or extrinsic to the airway) need appropriate intervention for diagnosis and removal Croup treatment consists of corticosteroid therapy in all cases, and the addition of racemic epinephrine and oxygen for more severe episodes with stridor at rest or significant respiratory distress (see Chapters 75 Stridor , 94 Infectious Disease Emergencies ) Treatment of pneumonia depends on the age and suspected pathogen (see Pneumonia, Community-Acquired Pathway https://www.chop.edu/clinical-pathway/pneumonia-community-acquired-clinicalpathway and Chapter 94 Infectious Disease Emergencies ) Patients with pertussis require antibiotics for eradication of the organism, and young infants or any child with significant paroxysms need hospitalization Patients with recurrent or moderate-to-severe hemoptysis require attention to airway, breathing, and circulation first and foremost Timely consultation with otolaryngology and pulmonology is warranted to assist in medical and procedural treatment of persistent bleeding Antitussive medications have limited value and should not be used routinely in young infants It is better to give specific therapy (e.g., bronchodilators in asthma, antibiotics in sinusitis) and avoid suppressing a cough in conditions with increased sputum production (e.g., asthma, pneumonia) In children older than year of age, honey may be a useful treatment for symptomatic relief of acute cough In older children with a nonproductive cough that interrupts sleep, antitussives can be prescribed Using cool mist humidifiers, elevating the head during sleep and suctioning the nares with nasal saline spray in infants can be beneficial for coughs associated with viral URIs Suggested Readings and Key References Abaya R, Crescenzo K, Delgado E, et al ED Pathway for Evaluation and Treatment of Bronchiolitis The Children’s Hospital of Philadelphia Posted: September 2005 Last revised: March 2018 Available at https://www.chop.edu/clinical-pathway/bronchiolitis-emergent-evaluationclinical-pathway Anne S, Yellon RF What are management options for chronic cough in children? Laryngoscope 2016;126(9):1963–1964 Bolton SM, Saker M, Bass LM Button battery and magnet ingestions in the pediatric patient Curr Opin Pediatr 2018;30(5):653–659 Bradley JS, Byington CL, Shah SS, et al The management of communityacquired pneumonia in infants and children older than months of age: clinical practice guidelines by the Pediatric Infectious Diseases Society and the Infectious Diseases Society of America Clin Infect Dis 2011;53(7):617–630 Brown JC, Chapman T, Klein EJ, et al The utility of adding expiratory or decubitus chest radiographs to the radiographic evaluation of suspected pediatric airway foreign bodies Ann Emerg Med 2013;62(6):604–608 Chang AB, Oppenheimer JJ, Weinberger MM, et al Etiologies of chronic cough in pediatric cohorts: CHEST guidelines and expert panel report Chest 2017;152(3):607–617 Chang AB, Oppenheimer JJ, Weinberger MM, et al Use of management pathways or algorithms in children with chronic cough: CHEST guidelines and expert panel report Chest 2017;151(4):875–883 Denipah N, Dominguez CM, Kraai EP, et al Acute management of paradoxical vocal cord motion (vocal cord dysfunction) Ann Emerg Med 2017;69(1):18– 23 Eliason MJ, Ricca RL, Gallagher TQ Button battery ingestion in children Curr Opin Otolaryngol Head Neck Surg 2017;25(6):520–526 Florin TA, Plint AC, Zorc JJ Viral bronchiolitis Lancet 2017;389(10065):211– 224 Gerber J, Metjian T, Siddharth M, et al ED Pathway for Pneumonia, Community Acquired The Children’s Hospital of Philadelphia Posted: September 2012 Last revised: November 2017 Available at https://www.chop.edu/clinicalpathway/pneumonia-community-acquired-clinical-pathway Green JL, Wang GS, Reynolds KM, et al Safety profile of cough and cold medication use in pediatrics Pediatrics 2017;139(6):e20163070 Haq IJ, Battersby AC, Eastham K, et al Community-acquired pneumonia in children BMJ 2017;356:j686 Janahi IA, Khan S, Chandra P, et al A new clinical scoring for the management of suspected foreign body aspiration in children BMC Pulm Med 2017;17(1):61 Litowitz T, Whitaker N, Clark L, et al Emerging battery-ingestion hazard: clinical implications Pediatrics 2010;125(6):1168–1177 Mackey JE, Wojcik S, Long R, et al Predicting pertussis in a pediatric emergency department population Clin Pediatr (Phila) 2007;46(5):437–440 Oduwole O, Udoh EE, Oyo-Ita A, et al Honey for acute cough in children Cochrane Database Syst Rev 2018;4:CD007094 ... battery-ingestion hazard: clinical implications Pediatrics 2010;125(6):1168–1177 Mackey JE, Wojcik S, Long R, et al Predicting pertussis in a pediatric emergency department population Clin Pediatr... Green JL, Wang GS, Reynolds KM, et al Safety profile of cough and cold medication use in pediatrics Pediatrics 2017;139(6):e20163070 Haq IJ, Battersby AC, Eastham K, et al Community-acquired... evaluation of suspected pediatric airway foreign bodies Ann Emerg Med 2013;62(6):604–608 Chang AB, Oppenheimer JJ, Weinberger MM, et al Etiologies of chronic cough in pediatric cohorts: CHEST