What are the treatment options for an 18-month-old child with a raspy cough and nighttime vomiting?

Management of an 18-Month-Old with Raspy Cough and Nighttime Vomiting

For this 18-month-old with raspy cough and nighttime vomiting, supportive care is the primary treatment—avoid over-the-counter cough and cold medications, ensure adequate hydration, and monitor for signs of respiratory distress or dehydration that would require immediate medical attention. 1

Initial Assessment and Safety Considerations

The most critical first step is recognizing what NOT to do:

• Over-the-counter cough and cold medications are contraindicated in children under 2 years of age due to lack of proven efficacy and potential for serious toxicity, including multiple reported fatalities. 1
• Between 1969-2006, there were 54 fatalities associated with decongestants in children under 6 years (43 deaths in infants under 1 year) and 69 fatalities associated with antihistamines (41 deaths in children under 2 years). 1
• Major pharmaceutical companies voluntarily removed these products from the market for children under 2 years in 2007. 1

Determining Acute vs. Chronic Cough

The duration of symptoms determines your diagnostic and management approach:

• If cough duration is less than 4 weeks, this is acute cough and most commonly represents a post-viral upper respiratory infection. 1
• Most acute viral coughs resolve within 1-3 weeks, though 10% may persist beyond 20-25 days. 1
• At 4 weeks duration, the cough becomes "chronic" and requires systematic evaluation using pediatric-specific algorithms. 1, 2

Supportive Care Measures (Primary Treatment)

Provide the following evidence-based supportive care:

• Ensure adequate hydration to help thin secretions—this is crucial for effective mucus clearance. 1, 2
• Use antipyretics (acetaminophen or ibuprofen) to keep the child comfortable and help with coughing. 1
• Gentle suctioning of the nostrils may help improve breathing if nasal congestion is present. 1
• A supported sitting position may help expand lungs and improve respiratory symptoms. 1

Addressing the Nighttime Vomiting

The vomiting in this case is likely secondary to the cough itself:

• Vomiting triggered by paroxysmal coughing is a common presentation and does not automatically indicate gastroesophageal reflux disease (GERD). 3
• GERD treatment should NOT be used when there are no clinical features of gastroesophageal reflux such as recurrent regurgitation, dystonic neck posturing in infants, or heartburn/epigastric pain. 4
• The fact that the child can go back to sleep after vomiting suggests this is cough-induced rather than primary GERD. 4

Red Flags Requiring Immediate Medical Attention

Instruct parents to seek immediate medical care if any of the following develop:

• Respiratory rate >70 breaths/min (for infants) or >50 breaths/min (for older children). 1
• Difficulty breathing, grunting, or cyanosis. 1
• Oxygen saturation <92% if measured. 1
• Not feeding well or signs of dehydration (decreased urine output, dry mucous membranes, lethargy). 1
• Bilious or bloody vomiting. 5
• Altered mental status or excessive irritability. 5

When to Escalate Evaluation

If symptoms persist or worsen, follow this timeline:

• Review by a healthcare provider if symptoms are deteriorating or not improving after 48 hours. 1
• If cough persists beyond 3-4 weeks, this transitions to "prolonged acute cough" and warrants further evaluation. 1
• At 4 weeks, obtain chest radiograph and consider spirometry (though spirometry may be challenging in an 18-month-old). 2
• Evaluate for specific cough pointers including coughing with feeding, digital clubbing, or failure to thrive, which would necessitate further investigations such as flexible bronchoscopy, chest CT, or assessment for aspiration. 4, 2

Specific Diagnostic Considerations at 4+ Weeks

If the cough becomes chronic (>4 weeks), determine whether it is wet/productive or dry:

• For wet/productive cough without specific pointers: Consider protracted bacterial bronchitis and treat with a 2-week course of antibiotics targeting Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis. 1, 2
• For dry cough: Consider post-viral cough, cough-variant asthma (though less common at this age), or upper airway cough syndrome. 2
• Do not use asthma medications unless other evidence of asthma is present (recurrent wheeze, dyspnea responsive to bronchodilators). 1

Environmental Factors

• Identify and eliminate environmental tobacco smoke exposure, which exacerbates respiratory symptoms and impairs secretion clearance. 1, 2
• Address parental expectations and concerns directly, explaining the typical course of viral respiratory infections. 4, 2

Common Pitfalls to Avoid

• Do not empirically treat for GERD based solely on cough and vomiting—this requires specific GI symptoms. 4
• Do not use cough suppressants or antihistamines in this age group. 1
• Do not use topical decongestants in children under 1 year due to narrow therapeutic window and risk of cardiovascular/CNS side effects. 1
• Avoid empirical treatment approaches not based on specific findings or suspected diagnoses. 2