Prevalence and Clinical Characteristics of Acute Cough in Indian Pediatric Population: Insights from Real-World Study

ABSTRACT

Introduction:

Coughing is a common symptom in children, often leading to healthcare visits. It is primarily linked to acute viral respiratory tract infections but can also result from bacterial infections, allergies, and asthma. Pediatric cough differs from adult cough in etiology and management due to the anatomical and developmental changes in the respiratory tract during childhood. This study aims to evaluate the prevalence, clinical characteristics, and types of cough in the Indian pediatric population through a retrospective real-world study.

Methods:

Electronic medical records of pediatric patients presenting with cough was studied to understand the prevalence and clinical features of acute cough in children <18 years.

Results:

Out of the total 22,51,735 patients, it was found that 5,75,284 patients (25.55%) reporting cough symptoms were children, indicating 1/4^th of the cohort was <18 years of age, which is a noteworthy proportion. Nonproductive cough (8.28%) was more prevalent than productive cough (4.55%). Additionally, nonspecific cough (87.17%), lacking identifiable causes, was more significant among children. A higher proportion (31.47%, 231,946) of pediatric patients consulted general physicians (GPs), for cough-related issues. Respiratory infection was the most frequently associated condition, followed by asthma and bronchitis. Fever and cold were common complaints in patients with both productive and nonproductive cough.

Conclusion:

This study highlighted the significant burden of cough in children and underscored the importance of understanding its prevalence, categorization, and clinical characteristics for effective management.

INTRODUCTION

Cough is a prevalent symptom observed in children of various age groups and often leads to healthcare visits.[1] Pediatric cough is primarily associated with acute viral respiratory tract infections (RTIs), although it can also be triggered by other conditions such as bacterial infections, allergic responses, and asthma.[2] It differs from the adult cough in terms of etiologies and management.[3] This might be due to the various anatomical and developmental changes of the respiratory tract during the childhood phase.[4]

Acute cough is a prevalent issue among children, particularly affecting those under the age of 5. Research indicates that preschool-aged children experience the highest incidence of acute respiratory infections, often accompanied by cough. This age group is particularly vulnerable due to their developing immune systems and anatomical differences in the respiratory tract.[5] Studies have been undertaken to examine the impact of pediatric cough on children and their families.[6] Pediatric cough gives rise to stress and anxiety in parents, due to its effect on child’s behavior (e.g., refusing food) and sleep patterns, and often unwarranted fear that it will escalate into a more serious health condition. Consequently, pediatric coughing often requires medical assistance, resulting in considerable expenses for doctor consultations, tests, and medications, thereby imposing a heavy burden on the healthcare system.[7]

The prevalence of pediatric cough in India has been documented in various studies, highlighting its significance as a common symptom among children. A study involving 204,912 patients indicated that cough was reported in 30% of cases, with pediatricians noting a prevalence of 41.6% among children seen in primary care settings.[8] This underscores the high incidence of cough as a presenting symptom in pediatric populations. Various guideline recommendations, consensus statements, and position statements are available only for chronic cough.[9,10] Moreover, there are fewer randomized controlled trials in children than in adults, so the evidence is less generous on the prevalence and management of acute cough in the pediatric population.[10] Also, clinical practice guidelines for adults outnumber those for children, and the adult guidelines do not translate well into the pediatric scenario.[11]

Overall, there are evidence gaps in various aspects of acute pediatric cough, such as the prevalence of cough symptoms, and frequency of consultation with respect to general practice or pediatric practice in primary care. In case of adults who are seeking medical attention, it is basically self-driven, but in children, parental and professional expectations impact consulting charges and prescription of medications.[3] To understand these gaps, the present retrospective real-world study was carried out in the Indian pediatric population. This study was planned to understand the prevalence of cough among pediatric patients, clinical characteristics, and characterization of cough.

METHODS

Study design

This retrospective observational study assessed the electronic medical records (EMR) data of pediatric Indian patients (<18 years) with complaints of acute cough at baseline to understand the prevalence and clinical characteristics. The patients who had complaints mentioned as chronic cough or related terms were excluded from the study.

Data collection and variables

Anonymized and aggregated data of the patients with cough from January 2017 to December 2023 was retrieved from the HealthPlix EMR database (https://healthplix.com/) for analysis. Since HealthPlix started its EMR in 2016 and by 2017 a pool of doctors started using HealthPlix for their day-to-day prescription, the duration from 2017 to 2023 was considered for data collection. The year 2017 may show a lesser number of patients, as only a fewer doctors started using the EMR. The data was analyzed to understand the incidence of cough, the prevalence of different cough categories, symptoms and associated conditions of acute cough in pediatric patients and for various specialties (general physicians [GPs], consulting physicians [CPs], pulmonologists, ear, nose and throat [ENT] specialists, and pediatricians). The patients were categorized based on their cough type into productive and nonproductive cough groups for data analysis. The term nonproductive cough was tagged for patients with complaints of dry cough, unproductive cough, allergic cough, cough with coryza, cough without expectoration, spasmodic cough, dry cough with rhinitis, cough without sputum, and cough without bronchospasm. The term productive cough group was tagged with patients with complaints of sputum cough, wet cough, cough with expectoration, fever with runny nose and wet cough, purulent cough, and cough with mucus. An “unspecified cough” was tagged with patients for whom the type of cough was not mentioned. Ethics Committee (EC) approval for the study was obtained from the Royal Pune Independent EC (IEC No. - RIPEC121123, Dated November 08, 2023). Since this was a retrospective analysis of the EMR data, registration on CTRI was not mandatory.

Statistical analysis

Statistical analysis for this study was carried out using Stata version 15.1SE (StataCorp., United States). Categorical data was summarized by doctor specialty using frequency (n) and percentages (%). The comorbidities and complaints were summarized using frequency (n) and percentages (%).

RESULTS

Incidence of acute cough

Complaints of cough were reported for 22,51,735 patients on the EMR platform from 2017 to 2023 where 575,284 patients (25.54%) belonged to the pediatric age group. Among them, nonproductive cough was reported in 8.28% of patients, and productive cough in 4.55%. The proportion of patients with unspecified cough was observed to be 87.17%. GPs ranked first, followed by pediatricians, in the number of patients consulted. [Table 1].

Table 1.

Overall incidence of acute cough in pediatric patients

Category	Specialties, n (%)					Total
	GPs (3060)	CPs (2675)	Pulmonologists (355)	ENT specialists (299)	Pediatricians (473)
Overall patients in the EMR with complaints mentioned as cough	737,055	1,081,830	179,111	52,549	201,190	2,251,735*
Total number of pediatric patients with cough complaints	231,946 (31.47)a	115,380 (10.67)a	17,089 (9.54)a	9679 (18.42)a	201,190 (100.00)a	575,284 (25.55)a
Pediatric patients with productive cough	7427 (3.20)b	10,061 (8.72)a	2772 (16.22)b	660 (6.82)a	5252 (2.61)b	26,172 (4.55)b
Pediatric patients with nonproductive cough	16,574 (7.15)b	15,749 (13.65)b	2816 (16.48)b	1928 (19.92)b	10,585 (5.26)b	47,652 (8.28)b
Pediatric patients with unspecified cough	207,945 (89.65)b	89,570 (77.63)b	11,501 (67.30)b	7091 (73.26)b	185,353 (92.13)b	501,460 (87.17)b

*Total number of patients with cough complaints attended by doctors of all specialties in the EMR, ^aPercentages are calculated by taking the number of overall patients in the EMR with complaints mentioned as cough as the denominator, ^bPercentages are calculated by taking the total number of pediatric patients with cough complaints as the denominator. EMR=Electronic medical records, GP=General physicians, CP=Consultant physicians, ENT=Ear, nose and throat, n=Number of patients

Associated conditions of pediatric patients with acute cough

Productive cough

RTI was the most commonly associated condition, followed by fever in pediatric patients (with productive cough) of GPs, CPs, and pediatricians. However, those consulted by specific specialists like pulmonologists had asthma and ENT specialists had pharyngitis as the second most associated condition [Figure 1].

Figure 1.

Top 10 associated conditions in pediatric patients with productive cough. RTI = Respiratory tract infections, COVID-19 = Corona virus disease-19, UTI = Urinary tract infections, COPD = Chronic obstructive pulmonary disease, GP = General physicians, CP = Consultant physicians, ENT = Ear, nose and throat

Nonproductive cough

Similar to the productive cough scenario, RTI was the most commonly reported associated condition in pediatric patients with nonproductive cough across the specialties. Following RTI, bronchitis was observed in the patients of GPs and CPs. The patients consulted by the pulmonologists, ENT specialists, and pediatricians had asthma, bronchitis, and gastroenteritis as the second most common associated condition, respectively [Figure 2].

Figure 2.

Top 10 associated conditions in pediatric patients with nonproductive cough. RTI = Respiratory tract infections, UTI = Urinary tract infection, COPD = Chronic obstructive pulmonary disease, COVID-19 = Coronavirus disease-19

Summary of complaints in pediatric patients with acute cough

Productive cough

Fever and cold were the most common complaints presented by pediatric patients with productive cough across GPs, CPs, pulmonologists, and pediatricians. However, a higher number of patients who consulted ENT specialists had cold and throat pain as common complaints. The other common complaints reported were headache, throat pain, chills, body ache, wheezing, shortness of breath, throat congestion, vomiting, etc. [Figure 3].

Figure 3.

Top 10 complaints in pediatric patients with productive cough. GP = General physicians, CP = Consultant physicians, ENT = Ear, nose and throat

Nonproductive cough

Patients with nonproductive cough consulting GPs, CPs, pulmonologists, and pediatricians commonly reported fever and cough as predominant complaints.

Among patients of pulmonologists, cold was the major complaint, followed by fever. ENT specialists noted cold and throat pain as primary complaints among their patients. Other prevalent complaints included headache, sneezing, nasal blockage, throat congestion, body ache, shortness of breath, chills, and runny nose among pediatric patients with nonproductive cough [Figure 4].

Figure 4.

Top 10 complaints in pediatric patients with nonproductive cough. GP = General physicians, CP = Consultant physicians, ENT = Ear, nose and throat

DISCUSSION

Cough is a significant concern in children, highlighting the need to assess its prevalence and management strategies aimed at addressing underlying causes rather than just alleviating symptoms.[12] This study contributes to understanding pediatric cough by evaluating its prevalence and clinical features within the Indian pediatric population. It is noteworthy from the study that about a 1/4^th of the patients reporting cough symptoms were children. Further, given that young children rarely expectorate sputum, distinguishing between productive (wet) and nonproductive (dry) cough is difficult.[13,14] Our study distinguished the type of cough and the prevalence of the specific cough types among the Indian pediatric population. The findings presented a higher incidence of nonproductive cough than productive cough in patients <18 years consistent with the observations of Narayanan et al. and De Blasio et al., who noted dry cough to be more prevalent in children.[15,16] The higher prevalence of nonproductive cough might be attributed to the rare expulsion of sputum by young children even when airway secretions are present.[17] Apart from this, several other aspects, such as anatomical and developmental factors, immunological responses, and environmental conditions, also contribute to the higher occurrence of dry cough among children.[18,19] This identification of the cough type assists primary care physicians in maintaining awareness and conducting regular reevaluations, rather than initiating immediate treatment.[12] The presence of a specific cough often suggests clinical features indicating an underlying cause, while a nonspecific cough lacks identifiable respiratory disease or known etiology even after a thorough assessment.[20] Described as typically dry and lacking known causes, nonspecific cough, or unspecified cough, encompasses any cough in children without signs of serious illness.[21] In our study, it was observed that the prevalence of nonspecific cough was higher among the pediatric population. This larger incidence of unspecified cough across all the specialties indicates the challenge in categorizing the cough as children rarely expectorate sputum with their cough.[22] The diagnosis of cough in the pediatric population becomes crucial here which can be achieved through a careful medical history and precise diagnostic tests for targeted treatment. The Indian Medical Association (IMA) in the cough algorithm booklet suggests various laboratory and diagnostic tests, including complete blood count, chest X-ray/radiograph, computed tomography scan, C-reactive protein test, etc. The IMA also suggests cough treatment based on underlying etiologies encompassing non-pharmacological and pharmacological therapies.[23]

GPs, CPs, or pediatricians assess self-limiting, prolonged, and potentially life-threatening courses of illness.[24] A prior investigation shows that cough is the most common pediatric issue addressed by GPs. Reports further reveal that two out of three children aged between 0 and 4 years visit their GPs at least once annually for acute respiratory infections, with up to three-quarters of them experiencing cough.[25] Consistent with these findings, the EMR data illustrated a higher proportion of pediatric patients consulting GPs, CPs, and pediatricians. This trend of increased GP and CP consultations has significant implications for healthcare delivery. This highlights the need for enhanced training in pediatric care for the GPs and CPs to ensure they are adequately equipped to manage common and complex pediatric conditions.[26] Moreover, the evaluation of pediatric cough at the GP level remains challenging as they present fewer symptoms compared to adults and due to the inability to establish the presence or absence of subjective symptoms.[27] However, the management of pediatric cough by GPs often remains suboptimal. This can be attributed to a lack of specialized knowledge, leading to potential misdiagnosis or inappropriate treatment, such as the overprescription of antibiotics for viral infections.[22]

Similar to adults, cough in children, whether attributed to URTI or acute bronchitis, is a common acute issue in primary care.[28] Shields et al. reported that viral URTIs are the primary cause of acute cough in children.[29] Davy et al. noted that children often presented with undifferentiated acute RTIs, which do not fit into any distinct diagnostic syndrome, such as croup, whooping cough, pneumonia, or bronchiolitis.[30] In line with this, the assessment of associated conditions in the current study also highlighted a higher prevalence of RTIs among pediatric patients presenting with acute cough. The study also identified fever and cold as frequently occurring complaints, aligning with prior research among pediatric patients with various respiratory conditions.[31,32] As most of the coughs in the pediatric age group are caused by RTIs, predisposing conditions of fever and cold in patients consulting GPs, CPs, pulmonologists, ENT specialists, and pediatricians. The occurrence of fever along with acute cough was seen in 81% (467,100 patients) of the pediatric patients in this study.

While this retrospective study examined the clinical implications of acute cough in pediatric patients such as the high prevalence of cough in pediatric population, higher incidence of nonproductive cough, need for enhanced training for GPs and CPs to ensure accurate diagnosis and avoid inappropriate treatments, higher association of pediatric cough with RTI, it did not assess cough severity or analyze the duration of the cough, representing a limitation of the study. The other limitations include missing data and increased data due to the addition of healthcare providers (HCPs) as the years progressed.

CONCLUSION

In conclusion, coughing in children represents a significant concern, underscoring the importance of understanding its prevalence and management strategies. Our real-world study provided valuable insights regarding acute cough among the pediatric Indian population, which was 1/4^th of the total cohort. The higher incidence of nonspecific coughs complicates the clinical assessment, emphasizing the challenges faced by the HCPs in accurately diagnosing and managing pediatric cough. Additionally, the predominance of nonproductive cough than the productive cough was also observed. A larger proportion of pediatric patients were found to consult the GPs, CPs, and pediatricians. The study also highlighted RTI as the major associated condition with fever and cold being frequent complaints among children with acute cough. The epidemiology and the clinical characteristics of acute cough among the Indian children described in this study may prove valuable in comprehending its prevalence, identifying the key risk factors, and proposing optimal management strategies to overcome the burden of cough.

Conflicts of interest

There are no conflicts of interest.

Funding Statement

Nil.