Evaluation of children with chronic cough including obstructive sleep apnea: a single-center experience


Chronic cough in children may be due to a diverse range of etiologies. We aimed to evaluate children with chronic cough following a standardized cough algorithm and assess obstructive sleep apnea (OSA) as a possible etiology. In addition, cough resolution rates of two different treatment protocols in children with non-specific cough were compared. A total of 237 children referred for chronic cough were assessed and classified according to etiologies. Children with non-specific cough were assigned either in the early-arm (group-1, n = 13) or delayed arm (group-2, n = 23). The presence of OSA was evaluated using a pediatric sleep questionnaire, and polysomnography was handled in indicated patients. Asthma (n = 82) and protracted bacterial bronchitis (PBB) (n = 73) were the most frequent etiologies. Cough resolution was higher in group-1 (100%) compared with group-2 (50%) (absolute risk reduction (rr) = 43.48% [95% CI 21.38–65.58%]). Polysomnography revealed mild (n = 6), moderate (n = 7), or severe (n = 5) OSA in 18 children, with adenoid/adenotonsillary hypertrophy as the leading cause.

Conclusion: We recognized asthma and PBB as the most frequent causes of chronic cough in our cohort. Early treatment of patients with high parental anxiety might be beneficial. We also believe that further studies including larger series might eventuate in incorporation of assessment of OSA to standardized algorithms.

What is known?
• Chronic cough in children may be due to a diverse range of etiologies, including serious respiratory disorders. Thus, its correct diagnosis and treatment are essential.
• Although a well-defined reason of chronic cough in adults, obstructive sleep apnea (OSA) has not been been evaluated so far in children with chronic cough.
What is new?
• We examined OSA for the first time as a possible cause of chronic cough in children and detected OSA with polysomnography in cases who scored high pediatric sleep questionnaire (PSQ) scores.
• We believe that studies including larger series might eventuate in incorporation of assessment of OSA to standardized algorithms for children with chronic cough.

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Fig. 1
Fig. 2



American College of Chest Physicians


Apnea–hypopnea index


Flexible fiber-optic bronchoscopy


Gastroesophageal reflux disease




Obstructive sleep apnea


Obstructive sleep apnea syndrome


Persistent bacterial bronchitis


Pediatric cough specific quality of life




Pediatric sleep questionnaire


Upper airway cough syndrome


  1. 1.

    Asilsoy S, Bayram E, Agin H, Apa H, Can D, Gulle S, Altinoz S (2008) Evaluation of chronic cough in children. Chest 134(6):1122–1128. https://doi.org/10.1378/chest.08-0885

    Article  PubMed  Google Scholar 

  2. 2.

    Beck SE, Marcus CL (2009) Pediatric polysomnography. Sleep Med Clin 4(3):393–406

    Article  PubMed Central  PubMed  Google Scholar 

  3. 3.

    Berry RB, Brooks R, Gamaldo CE, for the American Academy of Sleep Medicine et al (2016) The AASM manual for the scoring of sleep and associated events: rules, terminology and technical specifications, version 2.3. www.aasmnet.org. Darien, Illinois: American Academy of Sleep Medicine

  4. 4.

    Birring SS, Ing AJ, Chan K, Cossa G, Matos S, Morgan MD, Pavord ID (2007) Obstructive sleep apnoea: a cause of chronic cough. Cough 3:7

    Article  PubMed Central  PubMed  Google Scholar 

  5. 5.

    Cash H, Trosman S, Abelson T, Yellon R, Anne S (2015) Chronic cough in children. JAMA Otolaryngol Head Neck Surg 141(5):417–423. https://doi.org/10.1001/jamaoto.2015.0257

    Article  PubMed  Google Scholar 

  6. 6.

    Chang AB, Glomb WB (2006) Guidelines for evaluating chronic cough in pediatrics: ACCP evidence-based clinical practice guidelines. Chest 129:260S–283S. https://doi.org/10.1378/chest.129.1_suppl.260S

    Article  PubMed  Google Scholar 

  7. 7.

    Chang AB, Newman RG, Carlin J, Phelan PD, Robertson CF (1998) Subjective scoring of cough in children: parent-completed vs child completed diary cards vs an objective method. Eur Respir J 11:462–466

    Article  CAS  PubMed  Google Scholar 

  8. 8.

    Chang AB, Landau LI, Van Asperen PP, Glasgow NJ, Robertson CF, Marchant JM, Mellis CM, Thoracic Society of Australia and New Zealand; Thoracic Society of Australia and New Zealand (2006) Cough in children: definitions and clinical evaluation. Med J Aust 184(8):398–403

    PubMed  Google Scholar 

  9. 9.

    Chang AB, Robertson CF, Van Asperen PP, Glasgow NJ, Mellis CM, Masters IB, Teoh L, Tjhung I, Morris PS, Petsky HL, Willis C, Landau LI (2012) A multicenter study on chronic cough in children: burden and etiologies based on a standardized management pathway. Chest 142(4):943–950. https://doi.org/10.1378/chest.11-2725

    Article  PubMed  Google Scholar 

  10. 10.

    Chang AB, Robertson CF, van Asperen PP, Glasgow NJ, Masters IB, Teoh L, Mellis CM, Landau LI, Marchant JM, Morris PS (2013) A cough algorithm for chronic cough in children: a multicentre, randomized controlled study. Pediatrics 131(5):e1576–e1583. https://doi.org/10.1542/peds.2012-3318

    Article  PubMed  Google Scholar 

  11. 11.

    Chang AB, Oppenheimer JJ, Weinberger M, Weir K, Rubin BK, Irwin RS (2016) Use of management pathways or algorithms in children with chronic cough: systematic reviews. Chest 149(1):106–119. https://doi.org/10.1378/chest.15-1403

    Article  PubMed  Google Scholar 

  12. 12.

    Chang AB, Oppenheimer JJ, Weinberger MM, Rubin BK, Grant CC, Weir K, Irwin RS, CHEST Expert Cough Panel (2017) Management of children with chronic wet cough and protracted bacterial bronchitis: CHEST Guideline and Expert Panel report. Chest 151(4):884–890. https://doi.org/10.1016/j.chest.2017.01.025

    Article  PubMed  Google Scholar 

  13. 13.

    Chang AB, Oppenheimer JJ, Weinberger M, Grant CC, Rubin BK, Irwin RS, CHEST Expert Cough Panel (2017) Etiologies of chronic cough in pediatric cohorts: CHEST Guideline and Expert Panel report. Chest 152(3):607–617. https://doi.org/10.1016/j.chest.2017.06.006

    Article  PubMed Central  PubMed  Google Scholar 

  14. 14.

    Chervin RD, Ruzicka DL, Giordani BJ, Weatherly RA, Dillon JE, Hodges EK, Marcus CL, Guire KE (2006) Sleep-disordered breathing, behavior, and cognition in children before and after adenotonsillectomy. Pediatrics 117(4):e769–e778

    Article  PubMed Central  PubMed  Google Scholar 

  15. 15.

    Galassi C, Forastiere F, Biggeri A, Gabellini C, De Sario M, Ciccone G, Biocca M, Bisanti L (2005) SIDRIA second phase: objectives, study design and methods. Epidemiol Prev 29(2 Suppl):9–13 [Article in Italian]

    PubMed  Google Scholar 

  16. 16.

    Gedik AH, Cakir E, Torun E, Demir AD, Kucukkoc M, Erenberk U, Uzuner S, Nursoy M, Ozkaya E, Aksoy F, Gokce S, Bahali K (2015) Evaluation of 563 children with chronic cough accompanied by a new clinical algorithm. Ital J Pediatr 41:73. https://doi.org/10.1186/s13052-015-0180-0

    Article  PubMed Central  CAS  PubMed  Google Scholar 

  17. 17.

    Gurgel RK, Brookes JT, Weinberger MM, Smith RJ (2008) Chronic cough and tonsillar hypertrophy: a case series. Pediatr Pulmonol 43(11):1147–1149. 58. https://doi.org/10.1002/ppul.20919

    Article  PubMed  Google Scholar 

  18. 18.

    Kaditis AG, Alonso Alvarez ML, Boudewyns A, Alexopoulos EL, Ersu R, Joosten K, Larramona H, MianS NI, Trang H, Tsaussoglou M, Vandenbussche N, Villa MP, Van Waardenburg D, Weber S, Verhulst S (2016) Obstructive sleep disordered breathing in 2- to 18-year-old children: diagnosis and management. Eur Respir J 47(1):69–94

    Article  PubMed  Google Scholar 

  19. 19.

    Kantar A (2017) Phenotypic presentation of chronic cough in children. J Thorac Dis 9(4):907–913. https://doi.org/10.21037/jtd.2017.03.53

    Article  PubMed Central  PubMed  Google Scholar 

  20. 20.

    Kantar A, Chang AB, Shields MD, Marchant JM, Grimwood K, Grigg J, Priftis KN, Cutrera R, Midulla F, Brand PLP, Everard ML (2017) ERS statement on protracted bacterial bronchitis in children. Eur Respir J 50(2):1602139. https://doi.org/10.1183/13993003.02139-2016

    Article  PubMed  Google Scholar 

  21. 21.

    Khoshoo V, Edell D, Mohnot S, Haydel R Jr, Saturno E, Kobernick A (2009) Associated factors in children with chronic cough. Chest 136(3):811–815. https://doi.org/10.1378/chest.09-0649

    Article  PubMed  Google Scholar 

  22. 22.

    Leconte S, Degryse J (2011) Prolonged cough in children in the primary care office. Rev Med Brux 32(1):5–9 [Article in French]

    CAS  PubMed  Google Scholar 

  23. 23.

    Lewis M, McClay JE, Schochet P (2000) Lingual tonsillectomy for refractory paroxysmal cough. Int J Pediatr Otorhinolaryngol 53(1):63–66

    Article  CAS  PubMed  Google Scholar 

  24. 24.

    Miller MR, Hankinson J, Brusasco V, Burgos F, Casaburi R, Coates A, Crapo R, Enright P, van der Grinten CP, Gustafsson P, Jensen R, Johnson DC, MacIntyre N, McKay R, Navajas D, Pedersen OF, Pellegrino R, Viegi G, Wanger J, Task Force ATS/ERS (2005) Standardisation of spirometry. Eur Resp J 26(2):319–338

    Article  CAS  Google Scholar 

  25. 25.

    Newcombe PA, Sheffield JK, Juniper EF, Petsky HL, Willis C, Chang AB (2008) Development of a parent-proxy quality-of-life chronic cough-specific questionnaire: clinical impact vs psychometric evaluations. Chest 133(2):386–395. https://doi.org/10.1136/thx.2009.133868

    Article  PubMed  Google Scholar 

  26. 26.

    Shields MD, Bush A, Everard ML, McKenzie S, Primhak R, British Thoracic Society Cough Guideline Group (2008) BTS guidelines: recommendations for the assessment and management of cough in children. Thorax 63(Suppl 3):iii1–iii15

    PubMed  Google Scholar 

  27. 27.

    Singh D, Arora V, Sobti PC (2002) Chronic/recurrent cough in rural children in Ludhiana, Punjab. Indian Pediatr 39(1):23–29

    PubMed  Google Scholar 

  28. 28.

    Teoh L, Hurwitz M, Acworth JP, van Asperen P, Chang AB (2011) Treatment of obstructive sleep apnoea for chronic cough in children. Cochrane Database Syst Rev (4):CD008182. doi: https://doi.org/10.1002/14651858.CD008182.pub2

  29. 29.

    Usta GB, Asilsoy S, Durmaz C (2014) The assessment and management of chronic cough in children according to the British Thoracic Society guidelines: descriptive, prospective, clinical trial. Clin Respir J 8(3):330–337. https://doi.org/10.1111/crj.12076

    Article  Google Scholar 

  30. 30.

    Weinberger M, Fischer A (2014) Differential diagnosis of chronic cough in children. Allergy Asthma Proc 35(2):95–103. https://doi.org/10.2500/aap.2014.35.3711

    Article  PubMed  Google Scholar 

  31. 31.

    Yüksel H, Söğüt A, Yılmaz O, Kutluay E (2011) Reliability and validity of the Turkish version of the pediatric sleep questionnaire: a tool for prediction of sleep related breathing disorder. Tuberk Toraks 59(3):236–241

    Article  PubMed  Google Scholar 

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We thank the children and their parents for participation in our study. We are also grateful to Prof. Atilla Halil Elhan for his help in our statistical analysis.

Author information




NC and NECI designed the study. NECI conducted and interpreted the statistical analysis and had the primary responsibility in the formation of the initial draft. All authors provided substantial contributions to the design of the work, or the acquisition, analysis, or interpretation of the data, revised the initial draft, approved the final manuscript, and agreed to be accountable for all aspects of the work.

Corresponding author

Correspondence to Nisa Eda Cullas Ilarslan.

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Conflict of interest

The authors declare that they have no conflict of interest.

Informed consent

Written informed consent was obtained from all individual participants’ parents included in the study. Additionally, participants above 8 years approved a pediatric informed consent.

Ethical approval

The study protocol was approved by the Ankara University School of Medicine Institutional Ethics Committee (Approval number: 19-800-15; Dec 2015). All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

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Communicated by Peter de Winter

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Ilarslan, N.E.C., Gunay, F., Haskologlu, Z.S. et al. Evaluation of children with chronic cough including obstructive sleep apnea: a single-center experience. Eur J Pediatr 178, 189–197 (2019). https://doi.org/10.1007/s00431-018-3276-x

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  • Asthma
  • Children
  • Chronic cough
  • Obstructive sleep apnea
  • Protracted bacterial bronchitis