Name: Pediatric cough — bulletproof documentation — ER Toolkit
Creator: Kim Trinh, MD

Most childhood cough is a self-limited viral illness — but a few are an aspirated foreign body, pertussis, pneumonia, or impending respiratory failure. The defensible chart documents the oxygen saturation and work-of-breathing, considers the sudden-onset foreign body and the pertussis exposure, and gives precise return precautions.

01What's at stake

A toddler with sudden coughing/choking and a unilateral wheeze has an airway foreign body until proven otherwise — a normal chest x-ray does not exclude it. A young infant with paroxysmal cough, post-tussive emesis, or apnea may have pertussis. And the child who is working hard to breathe — retractions, grunting, hypoxia — can tire and decompensate. The vital that anchors the chart is the SpO₂ and the breathing assessment.

02Can't-miss diagnoses

Aspirated foreign body — sudden choking/coughing, focal/unilateral wheeze or decreased breath sounds; a normal x-ray doesn't exclude it → bronchoscopy. → FB evaluation
Pertussis — paroxysmal cough, whoop, post-tussive emesis, apnea in the young infant; under-immunized → test, treat, and isolate. → pertussis eval
Pneumonia — fever, tachypnea, focal findings, hypoxia.
Respiratory compromise — retractions, grunting, nasal flaring, hypoxia, exhaustion → support and escalate. → SpO₂ / work of breathing
Asthma/reactive airways and croup (barky cough, stridor).

03History & exam

Pulse oximetry and work-of-breathing — the core assessment; respiratory rate, retractions, grunting, flaring, mental status. → SpO₂ / WOB
Sudden onset/choking episode, focal wheeze (foreign body); immunization status and exposure (pertussis); fever and focal findings (pneumonia).
Duration, feeding/hydration, prior episodes/atopy, and toxic appearance.
Imaging by suspicion — inspiratory/expiratory or decubitus films for a foreign body (recognizing their limits); CXR for focal/severe disease.

Skip the typing

Work the case in the Pediatric Cough Workup — it records the oxygen saturation/work-of-breathing, the foreign-body evaluation, and the pertussis assessment, and assembles an MDM that documents the dangerous causes were considered.

04Management

Foreign body: ENT/bronchoscopy for removal; keep the child calm; don't be falsely reassured by a normal film.
Pertussis: macrolide and isolation; treat/prophylax close contacts; admit young infants with apnea.
Pneumonia: antibiotics per guidelines; oxygen and admission for hypoxia/respiratory distress.
Respiratory support: oxygen, suctioning, bronchodilators where indicated, and escalation for the tiring child.
Viral cough: supportive care; avoid OTC cough/cold medicines in young children; explicit return precautions.

05What to document

▼ weak

"Cough and congestion. Viral. Discharged."

▲ defensible

"3-year-old, 2 days of cough/congestion with sick contacts. SpO₂ 98% on room air, no retractions/grunting/flaring, normal work of breathing and mental status. No sudden choking episode, no focal/unilateral wheeze (foreign body not suspected). Immunizations up to date, no paroxysms/whoop/post-tussive emesis/apnea (pertussis unlikely). Afebrile, no focal crackles or tachypnea (pneumonia unlikely). Viral URI — supportive care, hydration; no OTC cough medicine. Return precautions for fast/hard breathing, retractions, blue color, choking episode, poor drinking/wet diapers, persistent fever, or whooping/vomiting with cough."

06Where charts fail

Missing the aspirated foreign body — relying on a normal x-ray or no choking history.
Missing pertussis in the under-immunized infant (apnea risk).
No documented SpO₂ or work-of-breathing assessment.
Missing pneumonia or impending respiratory failure in the toxic/tiring child.
Recommending OTC cough/cold medicines in young children; vague return precautions.

07Sources

Chang AB, Oppenheimer JJ, Weinberger MM, et al. Management of children with chronic wet cough and protracted bacterial bronchitis: CHEST guideline. Chest. 2017;151(4):884-890.
Bradley JS, Byington CL, Shah SS, et al. Management of community-acquired pneumonia in infants and children: PIDS/IDSA guideline. Clin Infect Dis. 2011;53(7):e25-e76.
Tiwari T, Murphy TV, Moran J. Recommended antimicrobial agents for the treatment and postexposure prophylaxis of pertussis: CDC guidelines. MMWR Recomm Rep. 2005;54(RR-14):1-16.
Sahn B, Mamula P, Ford CA. Foreign body aspiration in children. Pediatr Rev. 2017;38(8):373-376.

Pediatric cough: documentation that holds up