What is the management approach for a pediatric patient presenting with cough and vomiting?

Management of Cough with Vomiting in Pediatric Patients

When a child presents with cough and vomiting, immediately consider pertussis (whooping cough) as the primary diagnosis, particularly if the cough is paroxysmal or post-tussive vomiting is present, and test for Bordetella pertussis infection. 1

Initial Clinical Assessment

Red Flag Features Requiring Immediate Attention

• Bilious vomiting at any age indicates intestinal obstruction until proven otherwise and requires immediate surgical evaluation 2, 3
• Altered sensorium, toxic/septic appearance, or inconsolable cry 2
• Severe dehydration or respiratory distress (respiratory rate >70 breaths/min in infants, >50 breaths/min in older children) 4
• Oxygen saturation <92% 4
• Bent-over posture suggesting acute abdomen 2

Pertussis-Specific Features

The combination of post-tussive vomiting, paroxysmal cough, or inspiratory whoop strongly suggests pertussis and warrants testing for recent Bordetella pertussis infection 1. This is particularly important as pertussis can present with vomiting triggered by coughing episodes rather than gastrointestinal pathology.

Diagnostic Approach Based on Cough Duration

Acute Cough (<4 weeks)

• Most acute coughs with vomiting are self-limiting viral illnesses 5
• Obtain chest radiograph only if hypoxia, rales, high fever (>39°C), or tachypnea/tachycardia disproportionate to fever are present 4
• Do not use over-the-counter cough and cold medications in children under 2 years due to lack of efficacy and serious toxicity risk, including 54 deaths from decongestants and 69 deaths from antihistamines in children under 6 years 4
• For children over 1 year, honey provides more relief than diphenhydramine or placebo 6

Chronic Cough (≥4 weeks)

• Obtain chest radiograph and age-appropriate spirometry (pre- and post-bronchodilator) 1
• Distinguish between wet/productive versus dry cough, as this determines the diagnostic algorithm 1
• For chronic wet cough without specific pointers: treat with 2 weeks of antibiotics targeting Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis (amoxicillin is first choice) 1, 6
• Do not empirically treat for asthma, GERD, or upper airway cough syndrome unless other features consistent with these conditions are present 1

Management of Vomiting

Hydration Assessment and Treatment

• Assess hydration status immediately 2
• For mild dehydration without red flags, use oral rehydration 2
• If intravenous fluids are needed, administer at 80% basal levels and monitor serum electrolytes 1

Antiemetic Use

Ondansetron is indicated for persistent vomiting preventing oral intake, with dosing of 0.2 mg/kg orally (maximum 4 mg) or 0.15 mg/kg parenterally 2. However, the FDA label specifies dosing for children 4-11 years as 4 mg, and 12-17 years as 8 mg for chemotherapy-induced vomiting 7.

Nasogastric Decompression

• Insert nasogastric tube for bilious vomiting to decompress the stomach 2
• Avoid nasogastric tubes in severely ill infants with small nasal passages as they may compromise breathing 1

Specific Etiologies to Consider

Age-Specific Life-Threatening Causes

In infants: congenital intestinal obstruction, malrotation with volvulus, pyloric stenosis, intussusception, sepsis, meningitis 2

In older children: appendicitis, intracranial mass lesion, diabetic ketoacidosis, toxic ingestions 2

Pertussis Management

When pertussis is clinically suspected based on post-tussive vomiting and paroxysmal cough, undertake testing for recent Bordetella pertussis infection 1. Early identification is critical for appropriate antibiotic treatment and infection control.

Environmental and Supportive Measures

• Determine and advise cessation of environmental tobacco smoke exposure 1
• Provide education on managing fever, preventing dehydration, and identifying signs of deterioration 4
• Ensure adequate hydration to thin secretions 4
• Use antipyretics to keep the child comfortable 1

Follow-Up Criteria

• Review within 48 hours if symptoms are deteriorating or not improving 4
• If cough persists beyond 3-4 weeks, transition to chronic cough evaluation with systematic algorithm 4
• Do not routinely perform additional tests (skin prick test, Mantoux, bronchoscopy, chest CT) unless individualized based on clinical symptoms and signs 1

Common Pitfalls to Avoid

• Never assume adult cough etiologies (GERD, upper airway cough syndrome, asthma) apply to children without specific supporting features 1
• Never use empirical treatment trials without a defined limited duration to confirm or refute the diagnosis 1
• Never dismiss post-tussive vomiting as simple gastroenteritis without considering pertussis 1
• Chest physiotherapy is not beneficial and should not be performed 1