What to do for a child with post-tussive vomiting and difficulty sleeping due to cough, with a clear chest examination to auscultation (listening with a stethoscope)?

Management of a Child with Post-Tussive Vomiting and Nocturnal Cough

Based on the child's symptoms of post-tussive vomiting and inability to sleep due to cough with clear chest examination, pertussis (whooping cough) should be considered as a possible diagnosis and appropriate testing and management should be initiated. 1

Diagnostic Considerations

• Post-tussive vomiting in children is suggestive of pertussis, with moderate sensitivity (60.0%) and specificity (66.0%) 1
• When evaluating a child with cough and post-tussive vomiting, assess for the three classical characteristics of pertussis:
  • Paroxysmal cough (recurrent prolonged coughing episodes)
  • Post-tussive vomiting (vomiting induced by coughing)
  • Inspiratory whooping (continuous inspiratory sound with whooping quality) 1
• Clear chest examination does not rule out pertussis, as the pathology primarily affects the airways rather than the lung parenchyma 2

Recommended Diagnostic Approach

• Consider pertussis testing when post-tussive vomiting is present in a child with acute cough (< 4 weeks duration) 1
• Obtain a chest radiograph to rule out other causes of cough, especially since the child has diminished sleep quality 1, 3
• When age-appropriate, perform spirometry (pre and post β2 agonist) to assess for possible reactive airway disease 1
• Tests for Bordetella pertussis should be considered, including PCR, culture, or serology based on availability 1

Management Plan

1. For immediate symptom relief:

   • Consider a cough suppressant such as dextromethorphan to help the child sleep at night, as it temporarily relieves cough due to throat and bronchial irritation and reduces the impulse to cough to help with sleep 4
   • Ensure adequate hydration, as coughing and vomiting can lead to dehydration 5, 6

2. If pertussis is suspected:

   • Initiate appropriate antibiotic therapy (macrolides such as azithromycin) early to prevent spread of disease, even though it may not alter the clinical course if started late 1, 2
   • Antibiotics are most effective when started early in the course of illness 1, 2

3. If symptoms persist beyond 4 weeks:

   • Reclassify as chronic cough and follow pediatric-specific cough management protocols 1
   • For children with prolonged wet/productive cough unrelated to an underlying disease, consider a 2-week course of antibiotics targeting common respiratory bacteria (Streptococcus pneumoniae, Haemophilus influenzae, Moraxella catarrhalis) 1, 7

Important Considerations

• Avoid empirical treatment approaches for conditions like asthma, gastroesophageal reflux disease, or upper airway cough syndrome unless other features consistent with these conditions are present 1
• If an empirical treatment trial is used, it should be of defined limited duration to confirm or refute the hypothesized diagnosis 1
• Parental concerns should be addressed, particularly regarding sleep disruption and vomiting, which can be distressing for both child and parents 6, 8
• Environmental factors that may exacerbate cough, such as tobacco smoke exposure, should be identified and eliminated 1

Follow-up Recommendations

• Schedule regular follow-up to monitor response to treatment and reassess if symptoms persist 7
• If cough persists despite appropriate management, or if new concerning symptoms develop, consider referral to a specialist 3
• Ensure vaccination status is up to date, as pertussis can occur even in vaccinated children due to waning immunity 2