What are the treatment options for a 3-year-old experiencing coughing and vomiting?

Management of a 3-Year-Old with Coughing and Vomiting

Immediate Assessment Priority

The first critical step is to determine if the vomiting is post-tussive (induced by coughing) versus independent vomiting, as this fundamentally changes your diagnostic and treatment approach. 1

Diagnostic Algorithm

If Post-Tussive Vomiting is Present (Vomiting Triggered by Cough)

Strongly consider pertussis (whooping cough) as the primary diagnosis, especially if the cough is paroxysmal in nature. 1

• Paroxysmal cough is defined as recurrent prolonged coughing episodes with multiple bursts of outflow and inability to breathe during spells 1
• Post-tussive vomiting in children with acute cough (<4 weeks) is moderately sensitive (60%) and specific (66%) for pertussis 1
• The combination of paroxysmal cough AND post-tussive vomiting significantly increases likelihood of pertussis 1, 2
• Listen for inspiratory whooping (continuous inspiratory airway sound with whooping quality), though this may be absent in young children 1

If pertussis is clinically suspected, obtain testing for Bordetella pertussis infection and initiate antibiotic therapy immediately without waiting for results. 1, 2

If Vomiting is Independent of Cough

Assess for red flag signs that require immediate intervention: 3, 4

• Bilious (green) or bloody vomiting - suggests intestinal obstruction requiring urgent surgical evaluation 3, 4, 5
• Altered mental status or lethargy 3, 4
• Severe dehydration (sunken eyes, decreased urine output, dry mucous membranes) 3
• Toxic or septic appearance 3
• Severe abdominal distension or tenderness 4

Initial Management Based on Cough Characteristics

For Acute Cough (<4 weeks duration)

Assess whether the cough is wet/productive versus dry: 1, 6

If Wet/Productive Cough:

• Consider protracted bacterial bronchitis if cough has persisted >4 weeks without other specific pointers 1, 6
• Initiate a 2-week course of antibiotics targeting common respiratory bacteria (Streptococcus pneumoniae, Haemophilus influenzae, Moraxella catarrhalis) 1, 6
• Amoxicillin is the first-line antibiotic choice for children under 5 years 1
• Alternative antibiotics include co-amoxiclav, cefaclor, erythromycin, clarithromycin, or azithromycin 1

If Dry Cough:

• Consider post-viral cough if following recent upper respiratory infection 6
• Evaluate for asthma if associated with wheeze, exercise intolerance, or nocturnal symptoms 6
• Consider upper airway cough syndrome (post-nasal drip) 6

For Pertussis-Suspected Cases:

Macrolide antibiotics (erythromycin, clarithromycin, or azithromycin) are the treatment of choice for pertussis. 1, 2

• Treatment is most effective when given during the cataral phase (early stage) 2
• Pertussis is highly contagious with 80% secondary transmission rate to susceptible contacts 2
• Household contacts require prophylactic antibiotics 2

Symptomatic Management

For Vomiting:

If vomiting is persistent and impedes oral intake, ondansetron is indicated: 3

• Oral dose: 0.2 mg/kg (maximum 4 mg) 3
• Parenteral dose: 0.15 mg/kg (maximum 4 mg) 3

Critical caveat: Do not use antiemetics if bilious vomiting is present, as this requires immediate surgical evaluation 3, 4

For Cough:

Do NOT use over-the-counter cough and cold medications, antitussives, or codeine-containing products in children. 6, 7

• These medications lack efficacy and carry risk of serious adverse effects 6, 7
• For children >1 year old, honey is the only evidence-based symptomatic treatment for acute cough 6

For Fever and Comfort:

• Use acetaminophen for fever reduction and comfort 1, 8
• Never use aspirin in children due to risk of Reye's syndrome 1
• Ensure adequate fluid intake to prevent dehydration 1

When to Hospitalize

Admit to hospital if any of the following are present: 1

• Signs of respiratory distress (markedly raised respiratory rate, grunting, intercostal retractions) 1
• Oxygen saturation <92% on room air 1
• Cyanosis 1
• Severe dehydration 1
• Altered consciousness 1
• Signs of septicemia (extreme pallor, hypotension, floppy infant) 1
• Inability to tolerate oral fluids due to persistent vomiting 1

Hospital Management if Admitted:

• Administer oxygen to maintain saturation >92% 1
• Switch to intravenous antibiotics if unable to absorb oral medications due to vomiting 1
• Appropriate IV antibiotics include co-amoxiclav, cefuroxime, or cefotaxime 1
• Provide IV fluids at 80% basal levels and monitor electrolytes 1
• Monitor oxygen saturation at least every 4 hours 1
• Do NOT perform chest physiotherapy - it is not beneficial and should be avoided 1

Common Pitfalls to Avoid

• Do not assume adult causes of chronic cough apply to children - the etiologies differ significantly 1
• Do not use empirical treatment for asthma, GERD, or upper airway cough syndrome unless specific features of these conditions are present 1, 6
• Do not routinely order extensive testing (CT scans, bronchoscopy, allergy testing) without specific clinical indications 1
• Do not delay evaluation of bilious vomiting - this represents intestinal obstruction until proven otherwise 3, 4, 5
• Do not overlook pertussis in a vaccinated child - vaccine immunity wanes and breakthrough infections occur 1, 2

Follow-Up

• Re-evaluate if child remains febrile or unwell 48 hours after initiating treatment 1
• If wet cough persists after 2 weeks of appropriate antibiotics, extend treatment for an additional 2 weeks 1, 6
• If symptoms persist beyond 4 weeks total, further investigation is warranted 1, 6