Scott Webb (Host): When it comes to pediatric respiratory illnesses and the associated symptoms and coughs, it could be a cold, it could be allergies, it could be lots of things. My guest is here today to tell us about pediatric respiratory illnesses, how they're diagnosed and treated, and really the importance of trusting our ears and instincts.

 Welcome to Conversations Like No Other, presented by Valley Health System in Ridgewood, New Jersey. Our podcast goes beyond broad everyday health topics to discuss very real and very specific subjects impacting men, women, and children. We think you'll enjoy our fresh take. I'm Scott Webb. Doctor, it's nice to have your time today. I'm a dad. I have two kids. They had coughs along the way, and I would wonder, is this just a normal, like, cold cough, or is this something more? And I, I'm sure that's something that a lot of parents go through. So we're going to really focus in on that today, you know, pediatric respiratory illnesses and some of the things that they can bring out in children and whether or not parents should be concerned.

So let's start there. Like, how can we distinguish between a normal cough, quote, unquote, normal cough, and one that's become you know, more prolonged or potentially concerning?

Lewis Kass, MD: That's a great question. And it's not easy to distinguish. I think that the best way to answer that question is to think of it as how long and how often. I sometimes when I meet families we'll act out, versus coughing. One is kind of pretty innocent sounding, and the other is a little scarier, I think.

Host: Right.

Lewis Kass, MD: And the scarier one is the one that I would say should be looked into.

Host: Mm hmm.

Lewis Kass, MD: And then if the scarier one happens again and again and again, it recurs, then that's a big red flag.

Host: Yeah. Yeah. I like that. Just asking them, does it sound like this or does it sound like this? Right. And those of us parents in the audience, you know, over time, we begin to figure out, okay, that's normal and they probably just have a little bit of a cold or there's something, as you say, more of a red flag here. Just wondering what are some of the common causes of prolonged coughs in children?

Lewis Kass, MD: The big one that

we all worry about and families worry about is asthma. And one of the defini, half of the definition of asthma in a very loose way is recurrent episodes of cough or wheeze. The other half of that definition is that responds to asthma medicine, but recurrent episodes of cough or wheeze.

But what else can cause coughing? Post nasal drip, all that drippage of mucus from the back of the throat can cause a lot of coughing. Having big tonsils and adenoids that, by the same token, drip mucus in the back of the throat, that's a real common reason for chronic cough. Having a lot of fluid pushing out against the eardrums. A lot of people don't realize that there are a lot of cough nerves that are on that eardrum and stretching those nerves from fluid, whether that fluid is infected from an ear infection or just fluid, is gonna cause chronic cough. And so that's another one. Acid reflux. Oh, that's a big one. Big reason for coughing. Chronic sinus infection is another big one. So there's lots of reasons to have cough.

Host: Yeah. Well, and it seems like one of the biggest challenges, obviously, for parents and providers as well is, you know, that persistent cough. Like, how do we figure out, is it asthma? Is it allergies? Is it other conditions like acid reflux? You know, my 17 year old daughter, she loves all these flaming hot things, flaming hot onions and things.

And sometimes I think that she's got acid reflux. Right? And it's not a cold, or it's not allergies, or even, you know, chronic sinusitis. Like, how do you do that? How do you differentiate? You know, how do we, but especially you, how do you figure out which one it is?

Lewis Kass, MD: Well, so much of the detective work and it really kind of is detective work, is the history And you ask families what happened next? Were you given antibiotics? Did the antibiotics work? When you were coughing, did brown or yellow mucus come out? Were you given an inhaler by your pediatrician? Did the inhaler work? So, depending on the response to the questions, can take you down one path or another.

Host: Right.

Lewis Kass, MD: The physical exam will add clues. And then, if you're in my office, we will probably do a breathing test, and that will add additional clues.

Host: I like the way you put that. It does feel, having been through this with my kids, it does feel like, we're sort of on the case, if you will, that it is detective work, right, between parents and providers, as you say, you know, just the patient history, the kid's history, like, if your kid, your kiddo has their tonsils and they tend to be on the bigger side, or maybe we're talking adenoids, like, you know, that's how you begin to do the detective work, right? You look at the kid, you find out, do they have their tonsils? What have you tried? Let me hear them breathe. It is all a part of that process, right?

Lewis Kass, MD: Totally. And, I talk about the fact that when I'm in a room with a family, it's a medical relationship. It's a partnership. And we go through the process together. And that's the ideal of doing this. You have all the answers. And your child has all the answers. And it's my job to ask the right questions. And look at your child in just the right way. And then possibly to order just the right test.

Host: Yeah. You know, in preparing my notes today for our conversation, Doctor, I came across a tick cough, you know, and I was like, I think I know what that is, but I'm going to ask the expert. What is a tick cough? And how do you address that?

Lewis Kass, MD: That's one of my favorite topics. First of all, a tick cough or a habit cough, some people call it.

Host: Yeah.

Lewis Kass, MD: These are horrible phrases, but it is what it is. It's a cough that takes on a life of its own and really becomes something that the body does without needing to really do it. And the way I like to explain it to the child, especially, is that at one point, you needed that cough to happen. Maybe you had a cold, maybe you had an infection, and the body really, really needed that cough to happen. And your very, very smart brain wanted to help you out with that cough and that cough was very helpful in the moment.

But now that infection is gone, that cold is gone, but your very smart brain and body might not have realized that the cough is gone and are still helping you.

Host: Right.

Lewis Kass, MD: And so the body learned how to do this. And now it's kind of like muscle memory, and it just keeps going and going and going, even though it doesn't serve a purpose now.

Host: Yeah.

Lewis Kass, MD: And how can you distinguish a tick or habit cough? In two ways, if you ask the parent, parent will tell you, I want to pull every hair out of my head, when they hear the cough.

The cough is often very loud, harsh, barking, brassy. It can happen every two seconds. We often say that the habit cough is a waiting room diagnosis. While they're in the waiting room, doing paperwork, you can hear that cough from deep in, in the, uh, the office.

Host: Yeah.

Lewis Kass, MD: And, the best question to ask is, does the cough happen while the child is sleeping? And habit coughs happen all day during wakefulness, but then magically disappear during sleep. The treatment for habit cough is hypnosis, hypnotherapy,

Host: Interesting.

Host: Interes ting

Lewis Kass, MD: And to create a new brain body connection that the child learns how to teach the body not to cough now. And, it has outperformed psychotherapy, medicinal therapy, speech therapy, and every other kind of therapy, hypnosis. And, we as pulmonologists, if we choose, which I have chosen, we can subspecialize in learning hypnosis and, teaching this to our patients.

Host: I wanna keep moving along here, Doctor, and talk a little bit about pneumonia and whether or not a, you know, the signs of prolonged cough might be due to something, you know, really serious, like pneumonia.

Lewis Kass, MD: So again, it's about the clues, the detective work. Some of the clues about pneumonia is that pneumonia makes kids feel lousy and the parent will tell you that. The parent might tell you that there was high spiking fever or my child has been coughing for a week and a half straight and it sounds like a very wet cough. And they just are so washed out, they're pale, they can't sleep at night, they've been nauseous, they don't want to eat. The real part of pneumonia, the best detective work in pneumonia is your ears. And some people will say, well, what about a chest x-ray?

Don't we need a chest x-ray? And we as pulmonologists have the phrase you believe your ears more than your eyes. And, we often don't rely on chest x-rays for pneumonia because the, the ears are much more sensitive.

Host: Yeah, it's good to know that stethoscopes are not just for show, you know show you know they, they present well in TV and movies, but you actually use those things and you, and you really trust your ears. That's awesome. You know, all of us parents have tried Doctor these over the counter OTC remedies, Mucinex and things like that.

And so is that when those things don't seem to be working, you know, I'm trying to follow along with you here when we try things and they don't work and the cough persists or the ickiness persists, then it's probably time to see you, right. Or just see their pediatrician, for example.

Lewis Kass, MD: That's a good gauge. Just like you said, if they don't work. A parent will say to me, well, often they'll ask me, what do you think about these cough medicines like Mucinex? I gave my, son Mucinex, a parent might say. And my first question is, did it work? And, uh, if they say yes, I'll say, great.

Host: Right. A miracle. Right.

Lewis Kass, MD: But if it doesn't work, and they're still coughing, then that either means that it didn't work, because they don't always work, or there might be something more at play.

Host: Yeah, more play for sure. And that makes me think about asthma. We touched on that earlier and just trying to understand in the context of this, you know, relatively short podcast anyway, but, you know, how does asthma present, especially in young children? What can we watch out for, be on the lookout for, especially related to that cough that is the common thread here throughout this podcast?

Lewis Kass, MD: So, the way I love to explain it to families is the way I think about it in its most simple form. Recurrent episodes of cough or wheeze that respond to asthma medicine. So, two parts of that definition. So, if a family comes in and says that every time my child gets a cold, the cough from that cold, oh my god, it lasts for like three or four weeks. And, my pediatrician gives me this liquid medicine that goes in the machine, the nebulizer? That's right, the nebulizer. And does it help? Yeah, yeah, it helps. The cough goes away for a few hours. I said, well, you know, the definition, recurrent episodes of coughing. So you got that. And that cough responds to albuterol.

So that's pretty convincing to me. So that's you know, the, the very, very basic bones of that story. Of course can be a little more complicated. You know, it's often a little more complicated. But it's usually right in that ballpark. So prolonged coughs with colds. That's the most common presentation for a child with asthma. Wheezing happens. Sometimes a child will say that my chest is whistling. A parent might hear the wheezing. It's funny, some of the co workers that I cut my teeth with years and years ago. One of them asked a mother, does your child have asthma? And the parent said, Well, I have a nebulizer. So that was her definition of having asthma.

Host: Right. If you have a nebulizer, then you must have asthma course. Yeah. It's really interesting, Doctor and I'm glad we're going through all these kind of, you know, on a step by step basis. I want to move to allergies and just talk about how allergies can contribute to respiratory symptoms in kids. And especially what are the treatment options?

Like I know my daughter has like seasonal allergies, so that's an easy fix. Take this little pill but, beyond that, the simple OTC remedies, how do you treat allergies in kids?

Lewis Kass, MD: So allergies mean that your body is sensitive to something in your environment. And that could be pollens, or grass, or dust, or a myriad of things, and you either inhale it, or eat it, or touch it, and your body gets inflamed by it. And they're all around us, and it's different for everybody, and if you breathe in all this grass and stuff, and it's all lining your nose and the back of your throat, and you get inflamed by it, and things get a little swollen, then all that mucus starts dripping. So there's your coughing, and your nasal passageways get all swollen, and now it's hard to breathe, and maybe you have to start breathing through your mouth, and now you're not going to sleep very well with your mouth open.

And you're going to toss and turn and have a horrible nighttime sleep because you're coughing and mouth breathing and it's a real mess. Uh, so what are you going to do about that? Well, if you're all swollen in the nose and the back of the throat, simple, unswell me. And what can you do to unswell all the swelling in the nose?

Well, there's nasal steroids that are over the counter now. There's Flonase and Nasonex and Rhinocort, uh, Nasocort, they're all over the counter. So you, most kids need one or two squirts per nostril once a day. And there really is nothing better than a nasal steroid for a swollen nose. I'm also a big fan of those sinus rinses.

Clean out that nose before bed. So that you can spend the whole night sleeping without all that junk in your nose, continuing to inflame the nose. But what I love, love, love, love, love, air purifiers.

Have a big, tall air purifier in the bedroom, or whatever room the child spends the most time in, which is usually the bedroom, and clean out that air.

Host: Yeah.

Lewis Kass, MD: And it doesn't have to be the Cadillac of air purifiers. A middle of the road air purifier, which they sell in Target, is all you need.

Host: Doctor, I suffer from GERD, you know, acid reflux. And sometimes when I don't take my pill, that brings up a little bit of a cough in me and I'm guessing it does for kids as well. So just wondering, when we think about these respiratory symptoms, where does acid reflux fit in there?

Lewis Kass, MD: Acid reflux, we call the great masquerader. Acid reflux can masquerade as asthma, chronic cough, a heavy breathing that is not asthma. All it takes is a little bit of acid to climb up into the esophagus, even a little bit of an inch. And there are nerves that connect to the lungs and the, the large airways of the lungs that make the lungs constrict and cough. And a little bit of acid, and there you are coughing and breathing heavily. If you think about it, one job of, say, the vocal cords right at the top of the trachea is to protect the trachea, protect the lungs from any food stuff or any something something from getting into the lungs.

So if a little bit of acid starts climbing up into the esophagus from the stomach, that's like a warning signal of, Hey! Hey! Be on guard, there's something coming up from the stomach, so get ready to close the vocal cords and be on guard to shut down and get ready to cough and expel anything that might come up to the top of the lungs, and it's a protective mechanism.

Host: So other than maybe, you know, the over the counter things like Tums or whatever, how do you manage acid reflux in kids?

Lewis Kass, MD: Medicine is a mainstay.

Host: Yeah.

Lewis Kass, MD: You know, people have gotten all scared recently about the Prilosecs and Prevacids and Nexiums, but the pendulum swung too far in one direction.

Host: Sort of over corrected.

Lewis Kass, MD: Yeah, we used to have these premature babies on Prevacid for 12 months straight on mega doses and they were all fine.

So I tell the families that look, go on Prevacid for two or three weeks. Let that area between the esophagus and the stomach heal and let that muscle between the esophagus and the stomach tighten up again and then you'll stop it.

Host: Right. And as we're learning from you today, learning from an expert when it comes to the detective work, right? So if you suspect that that sort of persistent cough is being triggered by acid reflux, and your child stops that cough when you start treating the reflux. Well, then you've solved the case, most likely, right?

Lewis Kass, MD: That's right? If you do something and it works, that was the answer.

Host: Right. It just seems so simple, but I can say that in hindsight now with both of my kids, one's 17, one's 21, when they were little, I didn't feel like, you know, such a great detective, but I feel like I'm really, I'm really on top of things now. If I had another one, boy doc, I would really, I'd just be the best dad ever.

Good stuff today as we're getting closer to finishing up here, just want to make sure I understand, you know, really when we talk about or think about these persistent coughs and what could be the causes and the myriad of possibilities, are there any real diagnostic tests or procedures?

You know, we've talked about you get patient history and you do physical exam and you really listen literally and figuratively, but how do you really diagnose ultimately?

Lewis Kass, MD: Well, we have small handful of tools at our disposal. We've got the x-ray, we've got our breathing tests where we blow into a computer and see how the air flows. So we use the breathing test to look for asthma, really for anything, you know, for weak muscles. then things start getting a little fancier.

We've got CT scans, CAT scans, and MRIs. We've got the ability to put a camera into the lungs through the nose or mouth so that we can look directly into the lungs and sample fluid so that we can see if there's infection in the lungs. Or to see if there's something blocking a tube in the lungs. That's our kind of mainstay.

Host: Yeah. And as we're saying also, in this journey of detective work, right? It's, it's physical exam and listening and patient history and do you still have your tonsils and does it, you know, do these symptoms come up, you know, every time you go outside and you start breathing in the outside air. Between parents and kids and providers, we can figure it out, hopefully. I just want to find out, Doc, as we finish up, is there really anything we can do on the preventative side to reduce the likelihood of chronic respiratory issues and illnesses? Is there anything we can do or is it just more of a react and hope that we, you know, we guess right?

Lewis Kass, MD: Well, good hand washing is still always number one. During the, pandemic, when everybody was wearing masks, very few kids were getting sick. I'm not suggesting we do that, but it is interesting that when we were all wearing masks, nobody was getting RSV the way they're getting it again right now. But again, I'm not suggesting that, but good hand washing, not sending your child to school sick, if you know that they're sick.

Host: Yeah.

Lewis Kass, MD: Vaccinations are important, air purifiers, those are kind of the basics.

Host: Yeah, the mainstays, right? The greatest hits, if you will. Yeah, as you say, you know, and I've spoken with a lot of providers. Funny thing about those masks, kids didn't get as sick, adults didn't get as sick, but here we are today, not recommending wearing masks all the time like we did, but things we can do. Proper hand hygiene, staying home when we're sick and so forth. I really appreciate your time today. It brought a smile to my face along the way, reminiscing about my kids me and just hearing from an expert. So thank you so much.

Lewis Kass, MD: You know, can I share just one more thing?

Host: Of course. Go ahead.

Lewis Kass, MD: So here I am in a very cavalier fashion saying, yeah, give some acid reflux medicine. When my son was two weeks old, he had acid reflux, and here I am, Mr. Brave and Cavalier, I was quaking in my boots as I had Zantac in a syringe, about to give him his first dose of Zantac, and so, when it's your own child, I totally get it. Even Mr. Brave here, I was so frightened to give him the first dose of Zantac.

Host: I always try to remind myself, Doctor, when I'm speaking with experts is, you know, they're patients too. Their kids were patients too. And so it's that fine line of prescribing or recommending things to parents, but then when you're in, when you're in the comfort of your own home, you go, I don't know about this.

 I'm not so sure when my own kid. I mean, I, I think we all get that. We all understand. We're all just trying to do our best as, you know, both parents, providers, so forth. So thank you again.

Lewis Kass, MD: Alright, thank you for your time.

Host: And for more information about Pediatric Pulmonology at Valley, please visit valleyhealth.com or call 1 800 VALLEY1. That's 1-800 825-5391 to schedule an appointment.

Host: And if you found this podcast helpful, please share on your socials and check out our entire podcast library for topics of interest to you. And thanks for listening to Conversations Like No Other presented by Valley Health System in Ridgewood, New Jersey. For more information on today's topic or to be connected with today's guest, please call 201-291-6090 or email valleypodcast@valleyhealth.com. I'm Scott Webb. Stay well.