What is the best approach for supportive care in an infant with continuous coughing and post-tussive vomiting due to suspected pertussis (whooping cough)?

Supportive Care for Infant with Continuous Coughing and Post-Tussive Vomiting

Infants with continuous coughing and post-tussive vomiting require close monitoring for life-threatening complications, with hospitalization strongly recommended for those under 12 months due to high risk of apnea, severe hypoxia, and death. 1

Immediate Assessment and Monitoring

Hospitalize infants under 12 months with suspected pertussis for continuous cardiorespiratory monitoring, as they have the highest risk for severe and life-threatening complications including apneic spells, bradycardia, cyanosis, and death. 1, 2

Critical Monitoring Parameters:

• Continuous pulse oximetry and apnea monitoring - infants can present with apneic spells and minimal cough initially 1, 2
• Cardiac monitoring for bradycardia episodes during coughing paroxysms 2
• Serial complete blood counts - watch for leukocytosis with lymphocytosis, which correlates with disease severity and mortality risk 2
• Respiratory status assessment between paroxysms, as infants typically appear well between episodes despite severe disease 1

Nutritional and Hydration Support

Provide frequent small feedings to prevent aspiration and maintain nutrition, as post-tussive vomiting leads to substantial weight loss and feeding difficulties. 1

• Offer smaller, more frequent feeds immediately after coughing episodes when the infant is less likely to cough 1
• Consider nasogastric or intravenous hydration if vomiting is severe enough to cause dehydration or significant weight loss 1
• Monitor weight daily as patients with pertussis often have substantial weight loss 1

Respiratory Support

Provide supplemental oxygen and be prepared for intubation with assisted ventilation in infants showing signs of respiratory distress, severe cyanosis, or apnea. 2

• Minimize stimulation that triggers coughing paroxysms, as they can lead to hypoxia and bradycardia 2
• Suction secretions gently only when necessary, as aggressive suctioning can trigger paroxysms 2
• Position infant to facilitate drainage of secretions and reduce aspiration risk during vomiting episodes 1

Antimicrobial Therapy

Initiate macrolide antibiotics (preferably azithromycin) immediately when pertussis is suspected to prevent transmission to contacts, even though antibiotics started after the catarrhal stage will not significantly alter the clinical course. 3, 4

• Erythromycin is effective in eliminating the organism from the nasopharynx and reducing transmission 4
• Antibiotics are most effective when started early in the illness but should still be given to reduce infectivity 3, 5

Environmental Modifications

Maintain a calm, quiet environment to minimize coughing triggers, as paroxysms can be precipitated by stimulation and occur more frequently at night. 1

• Reduce environmental irritants and tobacco smoke exposure 3
• Ensure adequate humidification of inspired air 1
• Limit unnecessary handling and procedures that may trigger coughing episodes 1

Complication Surveillance

Monitor closely for complications that result from severe coughing pressure, including pneumothorax, subconjunctival hemorrhage, subdural hematoma, and seizures. 1

• Watch for signs of secondary bacterial pneumonia or otitis media 1
• Assess for neurologic complications including seizures and hypoxic encephalopathy 1
• Monitor for pulmonary hypertension in severely ill infants with marked leukocytosis 2

Sleep Management

Expect and plan for significant sleep disturbance, as paroxysms occur more frequently at night and patients often have substantial sleep disruption. 1, 3

• Continuous monitoring allows for immediate intervention during nocturnal paroxysms 1
• Position infant safely for sleep while facilitating secretion drainage 1

Common Pitfalls to Avoid

• Do not rely on cough suppressants or bronchodilators - they are ineffective for pertussis and may delay appropriate diagnosis 5, 6
• Do not discharge infants under 12 months prematurely - the paroxysmal stage typically lasts 2-6 weeks and complications can occur throughout 1
• Do not assume the infant is improving based on appearance between paroxysms - they often appear relatively well between episodes despite severe disease 1