What is the best course of management for a 16-month-old patient with severe nocturnal cough and vomiting, and a family history of asthma?

Management of Nocturnal Cough with Post-Tussive Vomiting in a 16-Month-Old

This child requires evaluation for pertussis and consideration of asthma given the nocturnal cough, post-tussive vomiting, maternal asthma history, and nasal congestion, with immediate management focused on supportive care and bronchodilator trial if respiratory distress develops. 1

Immediate Diagnostic Considerations

Pertussis Evaluation

• Post-tussive vomiting is a key clinical feature suggestive of pertussis, with moderate sensitivity (60%) and specificity (66%) for this diagnosis. 1
• The pattern described—coughing episodes followed by vomiting 10-15 minutes later containing mucus—fits the classical presentation of pertussis. 1
• Testing for Bordetella pertussis should be performed immediately using PCR, culture, or serology based on availability. 1
• If pertussis is confirmed or highly suspected, initiate macrolide antibiotics (azithromycin) early to prevent disease spread, even though antibiotics may not alter the clinical course if started after the paroxysmal phase has begun. 1

Alternative Diagnoses to Consider

• Given the maternal history of asthma, this child has significant risk factors for developing asthma, as maternal atopy is the strongest association with childhood asthma. 2
• The nocturnal predominance of symptoms and post-tussive vomiting can occur with asthma, though the clear chest examination makes active bronchospasm less likely at this visit. 2
• Gastroesophageal reflux should be considered in very young children (0-2 years) as it can mimic asthma symptoms. 2

Recommended Diagnostic Workup

Essential Investigations

• Chest radiograph should be obtained to rule out structural abnormalities, pneumonia, or other causes of chronic cough. 3, 4
• Pertussis testing (PCR preferred) given the clinical presentation. 1
• Spirometry is not feasible at 16 months of age as it typically requires children >6 years, though diagnosis in this age group relies almost entirely on symptoms rather than objective lung function tests. 2, 4

Clinical Assessment Points

• Evaluate for "specific cough pointers" including: coughing with feeding, failure to thrive, focal chest findings, hemoptysis, or digital clubbing—none of which appear present in this case. 4
• The 3-week duration classifies this as approaching chronic cough (defined as >4 weeks in children), though it remains in the acute phase currently. 4
• Assess whether the cough is wet/productive versus dry, as this significantly influences management. 3

Management Algorithm

If Pertussis is Confirmed or Highly Suspected

• Initiate azithromycin therapy immediately. 1
• Provide supportive care including hydration and monitoring for respiratory distress. 1
• Educate parents about the natural course: cough may persist for weeks despite antibiotics, but treatment prevents transmission. 1
• Ensure close contacts receive prophylaxis and verify immunization status. 1

If Pertussis is Ruled Out - Consider Asthma Management

Given the maternal asthma history and nocturnal symptoms, a trial of bronchodilator therapy is reasonable if respiratory distress develops or symptoms worsen. 2, 3

For children aged 0-2 years with suspected asthma:

• The bronchodilator response is variable in the first year of life, but bronchodilators should still be tried. 2
• If bronchodilator trial is initiated, use salbutamol 2.5 mg via nebulizer (dose for children up to age 2). 2
• Reassess 10 minutes after administration. 2
• Avoid empirical asthma treatment unless other features consistent with asthma are present—do not start inhaled corticosteroids without evidence of bronchodilator responsiveness or clear asthma symptoms. 3, 1

Symptomatic Management

• Continue current supportive measures: saline nasal drops for congestion, adequate hydration, and antipyretics as needed. 2
• Avoid over-the-counter cough and cold medicines, as they have not been shown to improve cough severity or duration in children. 3
• Do not use codeine-containing medications due to risk of serious side effects including respiratory distress. 3
• Ensure the child is positioned upright after feeds to minimize vomiting risk. 2

Red Flags Requiring Urgent Escalation

Transfer to emergency department or intensive care if any of the following develop:

• Respiratory rate >50 breaths/min, pulse >140 beats/min. 2
• Increased work of breathing with nasal flaring (already noted intermittently—monitor closely). 2
• Cyanosis, silent chest, exhaustion, or reduced level of consciousness. 2
• Inability to feed or maintain hydration. 2

Follow-Up Plan

Short-Term (Within 1 Week)

• Reassess in 3-5 days to evaluate response to any initiated treatment and review pertussis test results. 1
• If cough persists beyond 4 weeks total duration, reclassify as chronic cough and follow pediatric-specific chronic cough protocols. 1, 4
• Monitor growth parameters (weight, height) given maternal asthma history and potential future need for inhaled corticosteroids. 2

Indications for Specialist Referral

Refer to pediatric respiratory specialist if: 2

• Symptoms present from birth or perinatal lung problems
• Failure to thrive develops
• Persistent wet cough despite appropriate management
• Failure to respond to conventional treatment
• Frequent use of bronchodilators or need for inhaled corticosteroids >400 μg/day
• Recurrent episodes despite appropriate treatment 4

Critical Pitfalls to Avoid

• Do not empirically treat for asthma, GERD, or upper airway cough syndrome without supporting clinical features—this leads to unnecessary medication exposure in young children. 3, 1
• Do not assume viral URTI alone given the 3-week duration and specific symptom pattern—pertussis must be excluded. 1
• Do not delay pertussis testing while waiting for symptoms to evolve, as early identification prevents transmission. 1
• Environmental tobacco smoke exposure must be identified and eliminated if present, as it significantly worsens respiratory symptoms. 3, 4
• In the 0-2 year age group, other disorders may mimic asthma including gastroesophageal reflux, cystic fibrosis, and chronic lung disease of prematurity—maintain diagnostic vigilance. 2