Received: 6 February 2018
Accepted: 7 February 2018
The habit cough: Diagnosis and treatment
Miles Weinberger MD
University of Iowa, Iowa City, Iowa
University of California San Diego, Rady Children's Hospital, San Diego, California
Miles Weinberger, MD, University of California San Diego, Rady Children's Hospital, San Diego, CA.
Doctors Wright and Balfour-Lynn from the Royal Brompton Hospital in
London described the diagnostic characteristics of the Habit Cough in
55 children seen over a 6-year period.
The ages of the 55 children
(median ∼10 years) were virtually identical to that of the 140 children
in whom we made that diagnosis over a 20-year period at the
University of Iowa.
The prior duration of the cough was also similar,
median 3 months seen at Brompton Hospital and 4 months at our
clinic. Like our experience in Iowa, the doctors at the Brompton found
that a frequent repetitive cough totally absent once asleep was a
generally sufficient characteristic to warrant the diagnosis. However,
the similarity ended after the diagnosis was made. While many of the
Brompton patients continued to cough, some for weeks or months, the
patients in Iowa left the clinic without the cough
The Brompton physicians limited treatment to explanation
and reassurance. Similar to a report of children with this problem
from Mayo Clinic, (Rochester Minnesota)
more than 25 years
ago, many had persistent symptoms of this debilitating disorder
for weeks or longer. It was over 50 years ago that Dr. Bernard
Berman, a Boston allergist, termedthedisorderasHabitCough,
and described an effective treatment for this disorder in six
children, using measures that he described as relying “solely on
the art of suggestion.”
Stimulated by Dr. Berman's experience, we began to use a
suggestion therapy method in our clinic at the University of Iowa. Our
approach emphasized empowering the child with the ability to resist
the urge to cough and thereby interrupt what appeared be a vicious
cycle where the cough produced a focus of irritation in the airway that
acted as the nidus for the continued cough. Our initial report in 1991
described 9 children, median age 11 years, whose repetitive sustained
cough present for up to 2 years (median 2 months) was stopped using a
form of suggestion therapy during the clinic visit.
Cessation of the
cough occurred within 15 min of the suggestion therapy session
(30 min for 1 very skeptical very bright male adolescent). A 1 week
follow-up found one child with no recurrences and eight with minor
transient return of symptoms self-controlled with utilization of the
autosuggestion technique taught during the clinic visit (Table 1). Seven
of the nine could be contacted a median of 2.2 years later. Sustained
absence of cough was reported for those seven. A psychological
questionnaire, the SCL-90-R, completed by the families of those seven,
identified no abnormalities.
Following our initial report, we continued that diagnostic and
treatment approach. Diagnosis in the Pediatric Allergy and Pulmonary
Clinic at the University of Iowa was based on the same criteria
described in the Brompton report, a frequent repetitive cough totally
absent once asleep. Eighty-five patients seen over a 20-year period
had the typical cough present when seen in our clinic. Those patients
were treated with suggestion therapy by one of six pediatric
pulmonologists. Cessation of cough was accomplished with suggestion
therapy by the attending clinician in all but three patients. Details of
the treatment failures are described in a subsequent review of the
Fifty-five patients seen during the 20-year period had a
convincing history of active habit cough but were not coughing during
the clinic visit. Where cough was not present when seen in the clinic,
autosuggestion, the same principle as our suggestion therapy was
taught so that the child could prevent any return of cough from again
becoming chronic (Table 1). Patients were instructed to contact us for
return of cough that could not be managed with the autosuggestion
techniques. That occurred only once, where the pulmonologist seeing
the patient misdiagnosed a 9-year-old girl with nocturnal coughing as
Another method for treating habit cough was known as the
This involved wrapping a bedsheet tightly
around the child's chest with the strong suggestion that his would
enable cessation of coughing. We utilized that once when a young
immature child was unable to focus during a suggestion therapy
session. Hypnosis, which can be considered as a type of suggest
therapy, has also been described as effective for this disorder.
various methods of suggestion therapy that can be utilized by the
Pediatric Pulmonology. 2018;53:535–537. wileyonlinelibrary.com/journal/ppul © 2018 Wiley Periodicals, Inc.
practicing pediatric respiratory specialist and success described since
Dr. Berman's report in 1966, there should be no justification for this
chronic functional cough to continue for most children and
adolescents once the diagnosis is made. I have seen our experience
in Iowa reproduced at other institutions. Just recently, a first-year
allergy/immunology fellow at my current institution joyfully told me
1 day how she diagnosed habit cough and successfully treated a 10-
year-old boy she saw in her clinic using the principles described in our
As to the parents that did not accept the explanation of habit
cough at the Brompton, if the actively coughing child stops coughing
during the suggestion therapy session, the nature of the cough is then
self-evident. Explaining the self-perpetuation of the cough to the
parents should follow the suggestion therapy session. Once the cough
is stopped in the clinic, the patient should be told that they, and not the
doctor, stopped the cough. Since the urge to cough has been observed
by us to persist for up to a day after successful cessation,
autosuggestion was taught to used for any recurrences (described at
the bottom of Table 1).
The Brompton physicians reviewed some of the confusion
regarding the diagnostic terminology of this disorder. A publication
from an “Expert Panel”made up predominantly of physicians with adult
specialties, pulmonologists and neurologists, lumped together all age
groups with chronic functional cough.
Attributing the chronic
repetitive cough without an apparent cause to a tic disorder,
psychopathology, or just calling it a somatic cough disorder has not
been helpful in either understanding or treating this disorder. Parents
are likely to be disturbed at the suggestion that their child has a
psychological problem or a tic disorder (they have often heard of
Tourette's syndrome). However, a review of published case reports
found this problem predominantly affects children and adolescents.
The clinical characteristics of the small number of adults described with
persistent functional cough may be different than that seen by the
Brompton doctors or us in children and adolescents. The median age
for this disorder was about 10 years at both the Brompton and Iowa
clinics with a range that decreased inversely with adolescent ages
The habit cough is not rare. With the Brompton and our
experience at the University of Iowa averaging nine and seven per
year, respectively, it is likely that similar numbers will be seen at other
referral centers. This troublesome disorder is associated with
substantial morbidity, misdiagnoses, and inappropriate medical
treatment. Consistent with the advice in the publication from the
TABLE 1 Major elements of suggestion therapy to stop the habit cough
•Approach the patient with confidence that the coughing will be stopped.
•There is no value in providing an explanation for the parents first beyond saying that you will show the child how to resist the urge to cough. The
explanation will be self-evident if the cough is stopped. The parents are asked to simply sit quietly with cell phones off.
•Explain the cough to the child as a vicious cycle that started with an initial irritant, perhaps a cold, that is now gone. Now cough itself is the cause of
irritation that then causes more cough.
•Instruct the patient to concentrate solely on holding back the urge to cough, for an initially brief timed period, for example, one-half of 1 min.
Progressively increase this time period and utilize an alternative behavior, such as sipping lukewarm water or inhaling a soothing cool mist from a
vaporizer, to “ease the irritation.”
•Tell the patient that each second the cough is delayed makes it easier to suppress further coughing.
•Keep the patient focused by continuing to provide repetitive instructions. Emphasize that holding back a cough is difficult and takes a lot of
concentration, but providing reassurance that the patient can do it.
•Repeat expressions of confidence that the patient is developing the ability to resist the urge to cough; “it's becoming easier to hold back the cough,
isn't it”(nodding affirmatively generally results in a similar affirmation movement by the patient).
•When ability to suppress cough is observed (usually by about 10 min), ask in a rhetorical manner, “You’re beginning to feel that you can resist the
urge to cough, aren’t you?”(said with an affirmative head nod).
•Discontinue the session when the patient can repeatedly respond positively to the question, “Do you feel that you can now resist the urge to cough
on your own?”This question is only asked after the patient has gone 5 min without coughing.
•Autosuggestion: Express confidence that if the urge to cough recurs that the patient can do the same thing at home. We called this autosuggestion.
This involved expressing confidence that 15-min sessions at home concentrating on holding back the urge to cough using sips of lukewarm water
to “ease the irritation causing cough.”We emphasized that there should be no distractions from parents or sibs; this was the child's activity. For
patients with a convincing history of habit cough but were not coughing when seen, we provided autosuggestion instructions while reassuring the
patient that they would then be able to stop the cough.
FIGURE 1 Age of diagnosis of 140 children and adolescents
diagnosed with habit cough at the University of Iowa Pediatric
Allergy & Pulmonary Division over a 20 year period (with permission
from J Allergy Clin Immunl-Practice)
Brompton, the diagnosis in Iowa was also made by the characteristic
history of a repetitive cough that is absent once asleep. Little or no
testing is generally justified. Wright and Balfour-Lynn treated by
reassuring the parents and waiting for eventual cessation. For some
that means weeks or months of a continued troublesome cough before
attrition occurs. Specifics of treatment methods in the literature have
varied, but the unifying principle is suggestion that empowers the
patient with the ability to break the cycle of cough stimulating further
cough. If the cough is present when seen by the physician, showing the
patient how to stop the cough provides a cure and should be done by
all pediatric pulmonologists encountering this problem.
Miles Weinberger http://orcid.org/0000-0003-2341-2094
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How to cite this article: Weinberger M. The habit cough:
Diagnosis and treatment. Pediatric Pulmonology.