Child with chronic productive cough 5 years

[ljoan]

9 yr old daughter has a chronic productive cough.  She had pneumonia 3X before age 3, in left low lobe, in Right up lobe and the 3rd time in the L Low and R up.  She had up and low resp problems during this time.  CF test neg. None of the asthma meds helped.  At age 3 1/2 outgrew this.  She was well and did not cough for 12 months.  At age 4 1/2 she started coughing again.   The cough is clear with some white or some light yellow.  It looks kind of lacy. She usually gives 1 cough or no cough and out it comes. It is about the size of a quarter.  Sometimes it is clear.  Every once in a while, she will have a day of no sputum at all.  Her ped. said it is just allergies.  No wheezing past 6 years. Allergic to dust mites, dogs and cockroaches.  The allergist sent out her sputum and it came back neg. Recently pul. tested for CF( neg.), Immune  problems(neg.), Lung capacity normal. With a cold the sputum is more yellow and there is more to expel. It goes back to the usual amount without anitbiotics.  The pul said she either has asthma (productive cough is a symptom in Atlanta) or bronchiectasis. Wait CT b/c radiation.He put her on Asmanex 250. After several months it didn't help. A 2nd opinion from dif. pul said I could stop Asmanex so I did.  I have been keeping a journal and recording the times and amounts of phlegm.  Most days were 3-6 times a day she expelled phlegm.  I have cut all glutton and dairy from her diet 2 weeks ago and now the phlegm comes 2-4 times, slight improvement.  She clears her throat and sound raspy parts of the day. She will start coughing phlegm at dif times of the day. Sinus xrays normal, no problems with ears.  She is a little congested. Sneezes 1-2X almost every morn. Protonix for 3 weeks to see if GERD. Added a dry cough to prod. cough during this period.  The dry cough left w/ protonox.  Albuteral does seem to help stop the cough but inhaled steroids do not.  The ENT said her sinus look good.  Her comprehensive metabolic panel & CBC normal.

[Debser]

Acupuncture as an alternative or in addition to other treatments might help her. its very effective for pulmonary issues, and mucous is one of the elements for diagnosis in Eastern medicine. I don't know if thats something you would consider but I was at my wits end with my son and a mysterious chronic cough and acupuncture helped him greatly. Good Luck.

[ljoan]

Thanks. I made an appt with the pediatric Gastrointestinal Doctor.  I forgot to mention that my daughter never coughs at night and never has. She only has her productive cough during the day.  I put her on albuteral for  2 days every 4 hours.  She coughed up yellow junk 3 times and then clear 2 times the first day.  But since then, this past week it is even less times of 0-2 times a day.  The only thing we have done different is to take out wheat and dairy.  Since doing this, the cough is less and less but unfortunately still there  once or twice most days.  She is also very raspy sounding and clears her throat.  She was tested for CF twice and was very low, not even close to boarder line both times.  What type of doctor should I go to for testing for bacteria such as MAC?  Thanks again.

[National Jewish Health]

The studies and clinical information you cite suggests that the source of the productive cough is your daughter’s lungs and not from an upper respiratory site.  If that is the case, then she appears to have some type of chronic lung disease, assuming that GERD with recurrent aspiration has been completely ruled out.  In this regard, a clinically negative response to 3 weeks of Protonix does not rule out the diagnosis of GERD and her doctors might want to consider further test to definitively rule out that diagnosis.

If the cough and sputum are a reflection of intrinsic lung disease, not secondary to GERD or to any other cause of recurrent aspiration, for example laryngeal dysfunction, then the next step would be to determine the underlying lung disorder.  Bronchiectasis can develop with or without CF and is not rare.  You should confirm with the pulmonologist that the negative testing for CF was comprehensive enough to, for all practical purposes, effectively rule out the diagnosis of CF.  See the highlighted area in the following abstract from a recent (2007) report on extended CF mutation testing.

Other, rather uncommon, causes of the chronic productive cough would include Alpha-1 anti-trypsin deficiency, a condition called ABPM that can occur with asthma, and infection with an unusual bacterium, such as Non-tuberculous Mycobacteria.  Your daughter’s pulmonary specialist is acting responsibly in taking the risk of radiation exposure from CT scanning into account.  From here on that risk, one that can reasonably be quantified, should be weighed against the effect of this chronic illness on her lungs and, maybe, on her quality of life.  And, should the problem prove to be localized in one lung, the potential (and risks) of curative surgery.

One more thought.  The 12 month hiatus, during which she was free of cough and sputum might be seen as evidence that favors infection or GERD rather than an intrinsic lung disease.

Good luck,



Authors Full Name: Lebo, Roger V. Omlor, Greg J.
Institution: Department of Pathology, Akron Children's Hospital, Akron, OH 44308-1062, USA. ***@****
Title: Targeted extended cystic fibrosis mutation testing on known and at-risk patients and relatives.
Source: Genetic Testing. 11(4):427-44, 2007.
Abstract: This paper reports mathematically derived residual risks of being a carrier or being affected with cystic fibrosis following various screening scenarios to assist in interpreting test results and advising patients. While parental screening with 23 American College of Medical Genetics (ACMG) cystic fibrosis mutations defines the 64% of affected U.S. Caucasian fetuses with two detectable mutations, newborn screening for elevated immunoreactive trypsinogen (IRT) and sweat chloride identifies an additional 36% of affected newborns with zero or one detected mutation. The relatives of these affected newborns with less than two detectable mutations have higher posterior (after) 23 mutation-negative test risks of carrying undetected mutations. These calculations emphasize how knowledge of the mutations in the related affected patient substantially improves upon the quality of after-test advice to patients. Furthermore, negative tests of the partner without a family history and/or more extensive cystic fibrosis transmembrane conductance regulator (CFTR) gene testing also increases the likelihood that a negative report is truly negative. When a newborn patient with zero or one detected CFTR mutation has an inconclusive sweat test result, the sweat test should be repeated before ordering additional often unnecessary CFTR gene sequencing. Given the same composite mutation panel test