Cough
Definedas sound that occurs on sudden release of air under high pressure,which is generated by forceful contraction of expiratory musclesagainst a closed glottis.Clinical dilemma is to determine whethercoughing is associated with mild illness or more serious problem. Principal Causes of Cough
- Infection/inflammation
- Upperrespiratory tract infection
- Sinusitis
- Laryngitis
- Croup
- Tracheitis
- Bronchitis
- Pertussis
- Bronchiolitis
- Pneumonia
- Viral
- Bacterial
- Tuberculosis
- Chlamydia
- Legionella
- Nocardia
- Mycoplasma
- Fungal
- Histoplasmosis
- Coccidioidomycosis
- Aspergillosis
- Blastomycosis
- Protozoa
- Chemical pneumonia
- Aspiration pneumonia
- Cystic fibrosis
- Bronchiectasis
- Lung abscess
- Allergic disorders
- Allergicrhinitis
- Asthma
- Mechanical or chemical irritation
- Environmentalirritants
- Foreign body aspiration
- Bronchopulmonary dysplasia
- Congenital anomalies
- Cardiac failure
- Gastroesophageal reflux
- Swallowing dysfunction
- Immotile cilia syndrome
- Neoplasm
- Reflex cough
- Psychogenic, including habitual cough
Clinical Features and Diagnosis
Infection/Inflammation
Upper Respiratory Tract Infection
URI (commoncold) is acute viral infection.Common pathogens include rhinoviruses,parainfluenza viruses, respiratory syncytial virus (RSV), and coronaviruses.Other viruses that occasionally cause common cold are adenoviruses,enteroviruses, influenza viruses, and reoviruses.Usual clinical findings are watery,mucoid, or purulent discharge; dry, hacking cough; and inflamednasal mucosa.Diagnosis is clinical. Sinusitis
Usuallypresents with history of purulent nasal discharge and persistentcough of >10 days' duration. Less common presentationis combination of fever, headache, and facial pain or sinus tenderness.Usually clinical diagnosis.CT should be performed when orbitalabscess or intracranial complication is suspected. Laryngitis
Most frequentcause is viral URI.Hoarseness and dry, hacking cough,which may last up to 1 wk, are usual clinical findings.Usually clinical diagnosis. Croup
Characterizedby a barking cough and stridor ± fever.See Chap.63, Stertor, Stridor, and Airway Obstruction. Tracheitis
Often crouplikeillness with cough and stridor precedes sudden onset of respiratory distressand high fever.Clinical picture suggests bacterialtracheitis.See Chap.63, Stertor, Stridor, and Airway Obstruction. Bronchitis
Inflammatoryprocess affecting trachea and bronchi. Most episodes are causedby viruses (e.g., RSV, parainfluenza viruses, influenza viruses,rhinoviruses, and adenoviruses).Hacking cough appears several daysafter onset of typical URI. Rhonchi may be heard, but crackles areinfrequent. Presence of wheezing usually indicates presence of reactiveairways disease.Usually clinical diagnosis. Pertussis
B. pertussisinfection begins with nasal discharge, which is followed by paroxysmal coughthat often has staccato quality. Whoop may follow paroxysm.Fever may or may not occur.There is usually leukocytosis withpredominance of lymphocytes.Apnea is serious complication, especiallyin young infants.Duration of illness may be as longas 6–10 wks.Chest radiograph may be normal or showperihilar infiltrates.Positive direct immunofluorescent assayof nasopharyngeal secretions suggests diagnosis, but false-positiveand false-negative results occur.Positive nasopharyngeal culture confirmsdiagnosis. Bronchiolitis
Usuallycaused by RSV and occasionally by parainfluenza viruses, influenzaviruses, and adenoviruses.Occurs during winter months, oftenin epidemics.Rhinorrhea usually precedes cough,which may be persistent and harsh. Expiratory wheezing is prominentfinding.See Chap.75, Wheezing. Pneumonia
Definedas inflammation of lung parenchyma that may be caused by infection.Frequently presents with fever, cough,and respiratory distress. Crackles and wheezes may be heard on exam.Decreased breath sounds and dullness to percussion indicate areaof lung consolidation.Presence of pneumonia usually can beconfirmed by chest radiography, although early in illness radiographcan appear normal.Specific cause requires further investigation. Viral
Accountsfor most cases of pneumonia in infancy and childhood.Most common viruses causing pneumoniainclude RSV, parainfluenza viruses, adenoviruses, and influenzaviruses. Less common causes are rhinoviruses and coronaviruses.Cytomegalovirus and herpes simplexvirus may cause pneumonia in newborn or in immunocompromised individuals.May also be caused by measles, varicella,and Hantavirus infection.Chest radiograph frequently shows involvementof both lungs, with peribronchial thickening, perihilar linear densities,and patchy infiltrates. Segmental or lobar consolidation, hilaradenopathy, and pleural effusions are unusual.Nasal wash cultures or polymerase chainreaction (PCR) of nasal secretions may sometimes diagnose specificviral infection.RSV antigen may be detected by enzymeimmunoassay or immunofluorescent techniques. Bacterial
Pathogenscausing bacterial pneumonia vary with age of child.Most common causes of bacterial pneumoniain neonates are group B Streptococcus and gram-negative entericbacteria (E. coli, K. pneumoniae, P. aeruginosa).In infancy, childhood, and adolescence,S. pneumoniae is most common, whereas S. aureus and group A Streptococcusare much less common.H. influenzae type b has become unusualcause of pneumonia, since advent of H. influenzae vaccine.M. tuberculosis can cause infectionat any age.Clinical findings with bacterial pneumoniausually include fever, cough that may be productive of sputum inolder child, and some degree of respiratory distress.Leukocytosis with predominance of polymorphonuclearleukocytes is common finding.Pleural effusions and pneumatocelesare more frequent with bacterial pneumonia than with viral pneumonia.Chest radiograph usually shows segmentalor lobar infiltrate.Diagnosis of bacterial pneumonia canbe confirmed by positive blood, pleural fluid, or lung biopsy cultures.McCarthy et al. (1999) demonstrated that PCR may be used to diagnosepneumonia caused by S. pneumoniae using sample of pleural fluid.Pharyngeal or sputum culture that haslarge numbers of single organism is suggestive but not diagnostic.Counterimmune electrophoresis and latexagglutination tests have successfully detected bacterial antigensof S. pneumoniae, group B Streptococcus, and H. influenzae typeb in urine, so these tests may be diagnostic. Tuberculosis
Usual modeof transmission of M. tuberculosis infection is by inhalation.Positive skin test with PPD may beobserved 2–12 wks after exposure.Children with disease usually haveprimary pulmonary TB with cough and fever.In most cases of TB infection, individualis asymptomatic, primary complex of infection is not seen on chestradiograph, and disease does not progress.In TB disease, individual has clinicalor radiographic findings and disease may be pulmonary or nonpulmonary.Chest radiograph shows involvementof segment or lobe, usually with enlarged regional lymph nodes.With progression, cavitary lesions or miliary disease can occur.Acid-fast bacilli smears and culturesshould be performed in anyone with suspected TB. In young child,especially if cough is nonproductive, best culture material is fromearly morning gastric aspirate. Otherwise, isolation of tuberclebacilli by culture of sputum, urine, pleural fluid, cerebrospinalfluid, other body fluids, or biopsy material confirms diagnosis.Negative PPD never excludes infectionor disease with TB. Anergy may be due to young age, viral infections,immunosuppression, and severe disseminated TB. Chlamydia
Pneumoniadue to C. trachomatis usually occurs in infants 1–3 mosof age.Clinical findings include conjunctivitisor history of conjunctivitis, staccato cough, tachypnea, crackles,and mild peripheral eosinophilia. Fever is variable finding.Chest radiograph usually shows hyperinflationand bilateral interstitial infiltrates.Positive nasopharyngeal or eye cultureconfirms diagnosis. Legionella
Legionnaire'sdisease is transmitted by inhalation of aerosolized water contaminated withLegionella species.Most common cause of Legionella infectionin U.S. is L. pneumophila serogroup 1.Frequent findings include fever, nonproductivecough, headache, and myalgia.Chest radiograph usually shows infiltrate.Pulmonary nodules ± cavitation also may occur.Diagnosis can be confirmed in a numberof ways:positiveculture of sputum or lung tissuedetection of organisms on smears ofrespiratory tract secretions by direct immunofluorescent assay usingmonoclonal or polyclonal antibodiesDNA probesserologic testing using indirect immunofluorescenceantibody assay Increase in antibody titer to ≥1:128is also considered diagnostic. Nocardia
Nocardiaspecies are funguslike bacteria that live in soil.Lung is probable portal of entry aswell as most frequent site of infection.Most common agent in U.S. is N. asteroides.Clinical findings include fever, cough,chest pain, night sweats, malaise, and weight loss.Chest radiography shows scattered infiltrates.Stained smears of sputum, spinal fluid,or pus may reveal gram-positive rods that are variably acid fast.Positive culture confirms diagnosis. Mycoplasma
M. pneumoniaeis common cause of pneumonia in school-aged children and adolescents.Infection with this organism is uncommonin patients <5 yrs of age.Persistent nonproductive cough andfever are usual presenting features. Other findings include headache,myalgia, sore throat, and macular or papular rash. Crackles andwheezes may be heard on lung exam.Typically, chest radiograph shows patchy,unilateral, segmental, or subsegmental consolidation, but diffuse,bilateral, interstitial infiltrates may be seen.Cold agglutinin titer of ≥1:64 issuggestive of diagnosis, although other viral infections (adenoviruses,Epstein-Barr virus) also can produce elevated titer. Complementfixation test is most widely available serologic test, and titerof ≥1:32 during an acute respiratory illness is suggestive ofinfection. Fungal
Histoplasmosis
Endemicin eastern and midwestern U.S., especially in Mississippi and OhioRiver valleys.Infection occurs by inhalation of H.capsulatum spores, which are present in soil or dust in barnyardsor other areas that contain bird and bat droppings.>95% of infectionsare asymptomatic. Common presentation is acute influenza-like illness withpulmonary infiltrates and hilar adenopathy. Disseminated diseasewith fever, cough, pulmonary infiltrates, hepatosplenomegaly, andpancytopenia occurs most frequently in immunocompromised hosts.Culture of sputum, blood, or bone marrowconfirms diagnosis, as does demonstration of intracellular yeastsin smears of bone marrow or biopsy material from infected tissues.Detection of H. capsulatum antigenin urine or serum also can be used to diagnose disseminated disease.Single titer of ≥1:32 or 4-fold increase in yeast phase titersis presumptive evidence of active infection. H bands found in immunodiffusionantibody assay also suggest active infection. Coccidioidomycosis
Endemicin southwestern U.S. Transmission occurs by inhalation of dust-borne sporesof C. immitis.Primary infection is often asymptomatic,whereas symptomatic infection usually presents with fever and cough.Chest radiograph may show hilar adenopathyand calcification of healing primary lesion. Granulomatous lesionscan occur in lungs, lymph nodes, bones, joints, skin, and meninges.Typical clinical and radiologic findingsand positive skin test or ≥1:32 complement fixation antibodytiter are diagnostic. Spherules seen in tracheal aspirates, sputum,urine, or spinal fluid; biopsies of skin lesions or organs; or positivecultures from any of these sources are also diagnostic. Aspergillosis
Aspergillusspecies grow in soil and in decaying vegetation. Transmission isby inhalation of airborne spores.Different clinical presentations mayoccur:Allergicbronchopulmonary aspergillosis with low-grade fever, productivecough, episodic wheezing, transient pulmonary infiltrates, and eosinophiliaAspergillomas that do not invade lungtissueInvasive pulmonary disease with feverand productive coughDisseminated disease with involvementof skin (cutaneous papules and abscesses), heart (endocarditis),bone (osteomyelitis), sinuses (sinusitis), or brain (abscess). Chest radiograph may show patchy ornodular infiltrates or consolidation ± cavitation.Branching and septate hyphae in sputumsuggest diagnosis.Positive sputum or lung biopsy cultureconfirms diagnosis. Blastomycosis
Infectionwith B. dermatitidis is endemic in southeastern U.S. and in midwestern statesbordering the Great Lakes.Pulmonary, cutaneous, and disseminatedforms of disease can occur, but pulmonary disease is most commonin children.Clinical findings of pulmonary diseaseinclude cough, fever, malaise, chest pain, weight loss, and hemoptysis.Chest radiograph may show infiltrates,cavities, or nodular densities.Primary cutaneous blastomycosis maypresent with ≥1 subcutaneous nodules that eventually ulcerate.Disseminated disease produces granulomatouslesions, which may involve liver, spleen, bone, skin, and brain.Thick-walled single budding yeast formsmay be seen with 10% KOH preparations from sputum, spinalfluid, urine, or skin lesions.Positive immunodiffusion test on serathat shows precipitin bands (A and B) is evidence for active infection;however, bronchoalveolar lavage or lung biopsy may be necessaryto establish diagnosis in children with pneumonia.Serologic assays are not reliable fordiagnosis. Protozoa
P. cariniiinfection occurs almost exclusively in immunocompromised childrenand is common in those affected with HIV.Clinical findings include nonproductivecough and fever.Chest radiograph shows bilateral interstitialor air-space disease.Diagnosis is confirmed by demonstrationof organism in lower respiratory tract secretions or lung tissue.Induction of sputum in older childrenand adolescents, bronchoscopy with bronchoalveolar lavage, or lungbiopsy can be performed.Methenamine silver nitrate and toluidineblue O are most useful stains to identify thick-walled cysts. Chemical Pneumonia
Gasoline,kerosene, and charcoal lighter fluid are hydrocarbons with low surfacetension and viscosity. Because of these properties, aspiration intotracheobronchial tree can easily occur after ingestion.Acute onset of cough and respiratorydistress and history of ingestion are diagnostic. Within severalhours of ingestion, chest radiograph may show evidence of pneumonia,with infiltrates commonly in right middle and lower lobes. Aspiration Pneumonia
Interferencewith normal swallowing predisposes to aspiration of oral and gastricsecretions as well as food. Children with gastroesophageal reflux,tracheoesophageal fistula, or neurologic disorders with swallowingdysfunction are more prone to develop aspiration pneumonia.Onset of respiratory distress afterchoking, gagging, coughing, or vomiting episodes should lead oneto suspect aspiration pneumonia. Cystic Fibrosis
Common causeof chronic lung disease in children but also affects other organsystems with epithelial surfaces, especially intestine, pancreas,liver, and sweat glands. Mutations in CFTR gene located on chromosome7 result in abnormal ion transport across epithelial surfaces. Genetictransmission is autosomal recessive.Age of onset and clinical presentationvary widely. Earliest clinical manifestation is meconium ileus innewborn. Most common manifestation of respiratory disease is coughthat may be dry or productive. Other clinical findings include wheezing;nasal polyps; frequent large, foul-smelling stools; digital clubbing;recurrent rectal prolapse; and poor growth.Chest radiograph usually shows hyperinflation,irregular aeration with areas of patchy atelectasis, and accentuatedperibronchial markings.Bacterial organisms that commonly colonizerespiratory tract in this disease are S. aureus, H. influenzae,and gram-negative enteric bacteria, including P. aeruginosa.Sweat chloride level >60 mEq/Lis diagnostic.DNA mutation analysis is definitive. Bronchiectasis
Infectionor chronic inflammation of airways can cause bronchiectasis.May be focal (foreign body, local infection)or generalized (cystic fibrosis, chronic aspiration).Chronic productive cough with cracklesand rhonchi on lung exam are usual findings.Chest radiography may show persistentatelectasis or infiltrates that fail to resolve.Diagnosis may be confirmed by chestCT, which shows dilated bronchi that do not taper peripherally. Lung Abscess
May occur ± pneumonia.Most common organisms found in lungabscesses are Staphylococcus species and group A Streptococcus.Anaerobes also may play role in individuals with aspiration pneumonia.Persistent fever and cough are usualclinical features.Abscess (density with air-fluid level)may be seen on chest radiography, with confirmation by chest CT.Needle aspirate may reveal specificpathogen. Allergic Disorders
Allergic Rhinitis
Althoughusual clinical findings with allergic rhinitis are persistent orrecurrent rhinorrhea, sneezing, and itchy tearing eyes, nonproductivecough also occurs.See Chap.41, Nasal Discharge. Asthma
Definedas inflammatory disorder of smaller airways, which is characterizedby recurrent wheezing that is reversible with bronchodilator therapyor spontaneously. Another common manifestation is recurrent cough, ± wheezing,especially after exercise or at night.See Chap.75, Wheezing. Mechanical or Chemical Irritation
Environmental Irritants
Smoke, chemicalfumes, particulate matter from fire, and other environmental pollutantsand toxins may stimulate cough production.History of exposure is diagnostic. Foreign Body Aspiration
Aspirationof foreign body into bronchus commonly produces choking or gagging followedby persistent coughing or wheezing.Some common foreign bodies are food(nuts, seeds, meat), pins, tacks, and plastic tops.Chest radiography may show segmentalor lobar collapse or unilateral hyperinflation. Chest radiographstaken in inspiration/expiration or in right and left lateraldecubitus positions as well as fluoroscopy may demonstrate unilateralair trapping and movement of mediastinum away from affected side duringexpiration. In some cases, bronchoscopy is necessary to confirmdiagnosis. Bronchopulmonary Dysplasia
A form ofchronic lung disease that often follows neonatal respiratory distresssyndrome treated with endotracheal intubation, mechanical ventilation,and high concentrations of inspired oxygen.During course of disease, respiratorydistress waxes and wanes with intermittent cough.Crackles and rhonchi may be heard onlung exam.Hypoxemia and hypercapnia occur, andapnea may develop.Chest radiograph shows combinationof hyperinflation, prominent perihilar markings, and streaky densitiesthat may persist for many months. Congenital Anomalies
Congenitalanomalies that may produce cough include laryngomalacia, tracheomalacia,tracheoesophageal fistula, pulmonary sequestration, bronchogeniccyst, cystic adenomatoid malformation, and vascular rings and slings.See Chap.56, Respiratory Distress and Apnea, Chap. 63, Stertor, Stridor, and Airway Obstruction,and Chap. 65, Sucking and SwallowingDifficulty. Cardiac Failure
Pulmonaryvenous congestion occurring as manifestation of cardiac failuremay cause airway edema leading to cough. Other findings includerespiratory distress, tachycardia, hepatomegaly, and cardiomegaly.See Chap.7, Cardiac Failure. Gastroesophageal Reflux
Aspirationof stomach contents into lung may produce airway obstruction andpneumonia with coughing and wheezing. Another proposed mechanismfor cough and respiratory distress is the stimulation of esophagealvagal afferents by gastric contents to produce laryngospasm andbronchospasm.See Chap.55, Regurgitation and Vomiting. Swallowing Dysfunction
Disordersthat cause difficulty in swallowing may produce gagging, choking,and recurrent coughing.See Chap.65, Sucking and Swallowing Difficulty. Immotile Cilia Syndrome
Autosomal-recessivedisorder characterized by defects in ultrastructure of cilia that impairciliary motion and clearance of mucus from respiratory tract.1 form of this syndrome has been mappedto chromosome 9p21-p13, whereas another has been mapped to chromosome5p.Structural defects include absenceof dynein arms and radial spokes.Onset is in infancy or early childhoodwith chronic cough that is usually productive of sputum. Other manifestationsinclude chronic rhinitis, sinusitis, otitis media, bronchitis, andpneumonia.Chest radiograph may show hyperinflation,bronchial wall thickening, segmental atelectasis or consolidation,situs inversus, and bronchiectasis.Electron microscopy of cilia obtainedby nasal or bronchial biopsy brushing techniques demonstrates structuraldefects. Neoplasm
Chroniccough may occur with airway tumors (hemangioma, papilloma), mediastinal masses,and lung tumors, including metastatic lesions.See Chap.56, Respiratory Distress and Apnea. Reflex Cough
In somechildren, foreign body or cerumen in ear canal causes transientreflex cough.Persistent cough also has been attributedto hair lodged against tympanic membrane.Otoscopic exam is diagnostic. Psychogenic/Habitual Cough
Occasionallychild has persistent or recurrent cough with no evidence of underlying respiratorytract disease. Usually occurs in school-aged child after URI, andcough lasts for weeks.Cough is usually loud, harsh, and foghorn-like,disappearing during sleep and often decreasing when alone or onweekends.Otherwise, child is well and physicalexam and chest radiograph are normal.Often secondary gain can be identified.Some of these children may have emotional problems that requirefurther evaluation. Diagnostic Approach
In manycases history and physical exam are diagnostic.Age of child, duration of cough, qualityand characteristic features of cough, and associated findings narrowdiagnostic possibilities. Age of Child and Duration of Cough
In infantsand preschool children, most common causes of acute cough are viralURI, pneumonia (viral, bacterial, aspiration), laryngotracheobronchitis(croup), bronchiolitis, and foreign body aspiration.In school-aged children and adolescents,most common causes of acute cough are viral URI, bronchitis, andpneumonia (viral, bacterial, M. pneumoniae).Chronic cough lasts >3–4wks, although many coughs induced by acute viral URIs may persistfor a number of weeks after onset of infection.Most common causes of persistent coughin early infancy are pertussis, pneumonia (infection, aspiration),and cystic fibrosis.In later infancy and early childhood,recurrent viral URIs and asthma are most common causes of recurrentcough.Most common causes of recurrent orchronic cough in adolescents are asthma, smoking, cystic fibrosis,and psychologic problems. Periodicity and Quality of Cough
Asthma,pneumonia, cystic fibrosis, bronchiectasis, TB, and focal lesionscausing local irritation or infection cause persistent coughs.Recurrent viral URIs and asthma causeepisodic coughing.Paroxysmal cough suggests pertussisbut can also occur with Chlamydia and Mycoplasma infection.Dry, barking or brassy cough with voicechanges signifies laryngotracheal pathology.Loud, honking cough in older childthat disappears with sleep suggests habit or psychogenic cough.Neuromuscular disorders produce a weakand feeble cough.Loose rattling cough means that excesssecretions or exudate exist in airways. Moist cough with sputumproduction is hallmark of suppurative lung disease. Timing of Cough
If coughdisappears while asleep, it usually has psychologic basis.Recurrent episodes of nocturnal coughor after exertion suggest cough-variant asthma.Productive cough with morning awakeningis common with bronchitis secondary to smoking or cystic fibrosis. Nature of Sputum Production
Few infants or young children expectorate.Cough productive of purulent sputum is usually associated with bacterialpneumonia, cystic fibrosis, bronchiectasis, or lung abscess. Occasionally,the sputum is blood streaked.
Associated Findings
Presenceof fever suggests infectious process such as viral URI, pneumonia,croup, pertussis or TB.Hemoptysis suggests bronchitis, foreignbody, bronchiectasis, cystic fibrosis, TB, pulmonary hemosiderosis,or lung abscess.Cough associated with stridor indicatesairway obstruction. Evaluation
Etiologyof cough can usually be determined or at least suspected from historyand physical exam.Chest radiography shows pattern andextent of disease and is confirmatory in many instances.With suspected bacterial pneumonia,CBC and differential, blood culture, and sputum culture (older child)should be performed.If TB is suspected, intermediate-strengthPPD should be placed.Thoracentesis should be performed ifthere is significant pleural effusion because Gram and acid-faststains, cultures (viral, bacterial, fungal), PCR, and cytology mayprovide specific diagnosis.With segmental or lobar collapse unresponsiveto therapy, bronchoscopy should be performed to define obstructivelesion and to obtain cultures.Another useful test is sweat test inchildren with recurrent or chronic cough.With suspected pulmonary infectionin immunocompromised host, nasal wash cultures for viruses, andsputum and blood cultures for bacteria and fungi, should be performed.Empiric therapy may be started for gram-positive and gram-negativebacteria and for P. carinii infection, but bronchoscopy with bronchoalveolarlavage should be considered at early stage. If this is nondiagnostic,lung biopsy is next step. References
- Bachur R. Cough. In: Fleisher GR, LudwigS, eds. Textbook of pediatric emergency medicine, 4th ed. Philadelphia:Lippincott Williams & Wilkins, 2000:183–186.
- Chernick V, Boat TF, eds. Kendig's disordersof the respiratory tract in children, 6th ed. Philadelphia: WB Saunders,1998.
- del Rosario JF, Orenstein SR. Evaluation and managementof gastroesophageal reflux and pulmonary disease. Curr Opin Pediatr1996;8:209–215.
- Eigen H. The clinical evaluation of chronic cough.Pediatr Clin North Am 1982;29:67–78.
- Long SS, et al., eds. Principles and practice of pediatricinfectious diseases. New York: Churchill Livingstone, 1997.
- McCarthy VP, et al. Necrotizing pneumococcal pneumoniain childhood. Pediatr Pulmonol 1999;28:217–221.
- Morgan WJ, Taussig LM. The child with persistent cough.Pediatr Rev 1987;8:249–253.
- Online Mendelian Inheritance in Man (OMIM). McKusick-NathansInstitute for Genetic Medicine, Johns Hopkins University (Baltimore,MD) and National Center for Biotechnology Information, NationalLibrary of Medicine (Bethesda, MD), 2001. World Wide Web URL: http://www.ncbi.nlm.nih.gov/omim.
- Parks DP, et al. Chronic cough in childhood: approachto diagnosis and treatment. J Pediatr 1989;115:856–862.
- Pickering LK, ed. 2000 Red book: report of the Committeeon Infectious Diseases, 25th ed. Elk Grove Village, IL: AmericanAcademy of Pediatrics, 2000.
- Rudolph AM, ed. Rudolph's pediatrics, 20thed. Stamford, CT: Appleton & Lange, 1996.
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Book Source Details
- Book Title: The Diagnostic Approach to Symptoms and Signs in Pediatrics
- Author(s): Paul S. Bellet
- Year of Publication: 2006
- Copyright Details: The Diagnostic Approach to Symptoms and Signs in Pediatrics, Copyright © 2006 Lippincott Williams & Wilkins.
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Copyright Details: The Diagnostic Approach to Symptoms and Signs in Pediatrics, Copyright © 2008 Williams & Wilkins.
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