Cough 'til you puke...

This is the time of year it seems everyone's coughing. I've heard from more than one worried parent that their child coughs to the point of vomiting. In the medical world, we call this post-tussive emesis.

Post = after, tussive = cough, emesis = vomit

Kids tend to have a very active gag reflex, so they sometimes gag themselves and vomit with cough. This can be good, since it gets the mucus out of the back of the throat. You can try to teach older kids to hack and spit it out, cough and spit it out, gargle with salt water, and rinse mucus out of the nose.

Of course it's not fun to vomit after coughing because everything in the stomach comes up and makes a huge mess. Sometimes the vomit comes out of the nose, which can burn from the stomach acid. And vomiting can be very scary to kids.

Are there serious concerns when kids vomit from coughing? 

Yes. In medical school I learned that when kids cough to the point of vomiting we should consider whooping cough, pneumonia and asthma. In reality, I find that many kids with regular cough and colds can gag from cough, but I always consider the more serious options.

What should I do if my child vomits from a cough?

First, keep your cool. If a parent starts to get flustered, it makes the child more worried, which never helps.

Make sure your child's breathing is okay. Obviously he is coughing, but between coughs if the breathing rate is too fast or labored, he should be evaluated ASAP.

Rinse out your child's mouth (and nose if needed- saline drops or rinses work well for this). Vomit is just nasty tasting and can burn in the nose.

Treat the cough. If your child has asthma, give a breathing treatment or their rescue inhaler. If your child is over a year of age, you can use honey to help a cough. A tsp usually does the trick. Humidify the air with a vaporizer or humidifier. For more treatments see Cough Medicine: Which one's best.

When should my child be seen?

If your infant is under a year of age or your child has not had the whooping cough vaccines, he should be evaluated. Some babies with whooping cough stop breathing so many are hospitalized to monitor for complications. 

After a single episode of vomiting if your child's breathing is comfortable, just continue to manage at home.

If your child develops difficulty breathing or dehydration, he should be seen as soon as possible.

If your child continues to vomit after coughing but is comfortable between episodes, he should be seen during normal business hours at his regular doctor's office. 

My Child's Cough and Breathing Sounds Like...

Parents often bring in kids with a cough but can't describe what it sounds like. I sometimes get to hear it if they cough, but Murphy's Law also says that a child who coughs often throughout the night and frequently during the day will have a 15 minute period of no cough at the exact time the doctor is in the exam room.

photo source: Shutterstock

In all seriousness -- coughs, regardless of the source -- are usually worse at night, which means your  doctor won't usually get to hear the worst of it.

I often wish there was one place I could refer parents to so they could see what various coughs sound like, so I decided to put a list together. The internet is ripe with videos now, but I have spent many hours watching videos that weren't very helpful in order to find these. I'm sure I missed some of the best ones, so if you have one that you really like, please post in the comments below.

My next blog will be on how to treat cough and colds.

Regardless of how the cough sounds, if you are worried about your child's breathing or the sound of the cough, bring your child in to be seen.

Disclaimer: I have no ties to any of the videos below and am not responsible for any of the opinions or errors within them. Some are professionally done and others are videos parents uploaded. Some have advertisements which I do not necessarily endorse.

Croup

The initial seconds of this baby with croup stridor video show the typical croupy cough. At about 0:55 it shows the stridor that many kids with croup have. Stridor is a whistling sound as the baby breathes in (often confused with wheezing, which happens when you breathe out). It is common in croup and is caused by the swelling near the voice box. (Older kids and adults who get the same viruses that cause croup in younger kids often get laryngitis from the swelling near the voice box in a larger neck.)

This ER physician of TheEDExitVideo spends the first couple of minutes discussing what causes croup. At 2:27 sounds of stridor in an otherwise happy looking baby are shown. At 3:44 is a picture showing intercostal retractions (also seen with wheezing or other types of respiratory distress).

Dry Cough

Dry cough can be from an irritation in the throat, asthma, acid reflux, or any common cold. It can also come from a habit cough (often seen after an illness and goes away with sleep only to return when awake).

Laryngomalacia

Laryngomalacia wasn't on my original list because it isn't from a virus or bacteria causing illness, but it is a cause of noisy breathing in infants. It is caused by floppy tissues near the voice box (i.e. larynx). Linden's Laryngomalacia - 3 Months shows this breathing. It is often worst when baby is excited or fussy.

For more information on this (even a video of a scope into the airway), check out Children's Hospital of Philidelphia's Laryngomalacia page. 

Pneumonia

The cough with pneumonia can sound like a wet cough or dry cough, so no specific videos are for this cause of cough. The clues to pneumonia include a fever with cough, difficulty breathing between coughs, shallow breathing, shortness of breath with brief exertion, pain in the chest, rapid breathing, or vomiting after cough. Pneumonia can be caused from viruses and bacteria and can range in severity. Walking pneumonia generally means that the person is not sick enough to require hospitalization. Some pneumonias lead to severe difficulty breathing and require oxygen support.

Wet Cough

Wet cough can be from pneumonia or bronchitis, but also from postnasal drip with a common cold or allergies.

When kids "cough stuff up" it is usually the postnasal drip being coughed up, not mucus from the lungs coming up. The same is true if they "cough up blood". This blood is usually from a bloody nose draining into the throat, not from lung tissue. (Note: bloody mucus can be from more serious causes and if your child has no signs of blood in the nose or is otherwise ill, he should be properly assessed by a physician.) 

Wheezing

Wheezing is typical in asthma (and bronchiolitis). Many parents mistake the upper airway congestion sound that many kids make with postnasal drip as wheezing. Wheezing can sound like a whistle as a child breathes out. Ethan's wheezing shows a baby with noisy breathing without distress. This Wheezing - Lung Sounds Collection video has the sounds one would hear with a stethoscope, but if you put your ear against your child's back (without a shirt) you might be able to hear them. If you don't hear wheezing, but your child is struggling to breathe, it does not mean there is no wheezing! Treat like you would if you hear the wheeze.

Asthma

Asthma Attack in a child starts with information on asthma, then at 1:50 video of what retractions look like. 

Asthma attack shows the typical short breathing in phase with long exhale seen with an asthma attack. Also you can see the airway pulling in at the neck (retractions).

Bronchiolitis, often simply called RSV, but caused by many viruses

Bronchiolitis Cough, 3.5 months old shows a baby with a wet sounding cough, typical of bronchiolitis. 

Bronchiolitis is a video from the ER physician Dr Oller. He reviews causes of bronchiolitis, how it's spread, and how it affects the body. At 1:40 he discusses the natural progression of the simple cold into bronchiolitis. At 3:04 there is a picture of how we collect a nasal swab to help with diagnose of any viral illness.

Sick with Bronchilitis shows an infant with suprasternal retractions (sucking in at the base of the neck) and the typical cough associated with bronchiolitis. The man erroneously says "croupy", see below for croup.

RSV and Infant Treatment shows the best treatment for babies with RSV (or any bronchitis): suctioning. Some babies need this deep suctioning in the doctor's office or hospital. Others can get by with nasal aspirating at home. (Note, the next blog will be about treatments, but I have to say here that the bulb syringe is fairly useless for this.)

Whooping Cough

Pertussis - Whooping Cough: A Family's Story is an informational video on pertussis with the classic whooping cough in a child and pictures of a newborn with pertussis.


Silence the Sounds of Pertussis - Whooping Cough is a commercial for vaccinating, but it starts with the typical whooping cough sound.


Pertussis (whooping cough) shows a young infant with a cough from pertussis. Young infants do not always whoop, they stop breathing.

8 Year Old With Pertussis (Whooping Cough) shows a typical cough for an older child. Her positioning in front of the toilet shows that these kids often vomit from the force of the cough. The 2nd video from this same girl shows how normal and healthy kids can appear between episodes.

Holidays and family spoiled by illness... It's that time of year!

It is Thanksgiving morning as I write this. I am enjoying my quiet time as the family sleeps in. Extra time to blog because I'm not cooking today ... more on that later.

Wash hands to help prevent illness!

Yesterday was a typical day in our office for a day before a holiday. Sick kids came in with parents hoping for an insta-cure so they could enjoy the holiday with the extended family. A few wanted to fly back home with a febrile child and wanted our okay -- but of course didn't get it because even on an antibiotic they could spread illness if it is a virus, which most illnesses are. Some parents just called in because they were already out of town when their child got sick and they wanted to know what will make them better before the turkey celebration.

I'm sure most parents knew deep down that the answer would be "time". There is no insta-cure for most illnesses. Anyone with fever, cough, sore throat, or other ill symptoms should be kept away from the festivities. Even if the fever goes down with a fever reducer. Even if the last fever was before bed last night and it's down this morning. Fever can wax and wane and one needs to be fever-free (without a medication to bring it down) for 24 hours before we really consider it gone. People are most contagious when they are running a fever and the first few days of illness.

It stinks. I know. As a parent with a teen who has had a cough for over a week and is sleeping a disrupted 16-18 hours a day, I will miss Thanksgiving with extended family to avoid the spread of illness. Could we go? Sure. He hasn't run a fever all week. He's old enough that he can wash hands, cough into his elbow, and stay out of everyone's way. But he'd be miserable. And if one of the little ones got sick, I'd feel awful. Even if they got it elsewhere, I'd wonder if it was from him.

So I get it. It really stinks. Family from Tennessee and California are in town. We rarely see them and I want the cousins to get to know one another. But my teen isn't feeling well and I don't want the cousins to feel this way. I haven't started him on antibiotics to make him better faster because I know they wouldn't work. We are using a humidifier, lots of sleep, and waiting. He's refusing the nasal wash unfortunately... but I keep offering it!

This holiday season I wish everyone health, but if someone is sick, stay home. Don't spread the germs.

For more information on treating illnesses, see these links:

Fever
Cough and colds
Ear pain and infections
Wheezing in infants
Croup
Influenza
Tamiflu
Vomiting and diarrhea
Pink eye and other red eyes
Strep throat
Painful urination
Cough Medicines: Which One's Best?
Evolution of Illness

Sick, Sick, and More Sick.

Photo source: Shutterstock

It isn't news that we are experiencing a rough winter as far as illnesses go. Flu is all over the news. Schools have high rates of absenteeism. You hear coughs wherever you are in public places.

A few nuggets of information that might help you treat your family this sick season:

Fever

Fever is a symptom of illness and makes us feel achey and miserable, but the number on the thermometer does not necessarily correlate with the diagnosis or treatment needed. Look at your child. If they are happy with a fever, over 3 months and immunized, let it run its course. If they complain of pain (or if your immunized infant over 2-3 months is fussy) give a pain reliever/fever reducer. Push fluids to avoid dehydration. Treat other symptoms as needed. Don't worry if the temperature on the thermometer goes up ~ worry if your child is in severe pain, having difficulty breathing, or looks dehydrated.

Cough

Coughs do not need medicine generally. Honey (for those over 1 year) has been shown to be safer and more effective than other cough suppressants. Adding humidification to the air does wonders to loosen mucus and ease breathing.

If the cough is accompanied by rapid breathing, sucking in of the ribs or abdomen, or followed by vomiting, your child should be seen by a medical practitioner for further evaluation and treatment.

If your child has a history of asthma or other wheezing, it is okay to see if the rescue medicine (albuterol or levalbuterol) helps the cough. If not, it either is really bad wheezing that needs further evaluation or a cough. And don't forget your prevention medicine if you use it!

If your child has been exposed to whooping cough and develops a cough, please see your medical provider for evaluation and treatment.

Water's Power

Water is good for most illnesses. Increase fluids to prevent dehydration and help the body repair itself. Sips of water can help a sore throat and ease a cough. Add humidification to the air when the weather is cold and dry. Use saline to clear the mucus from the nose and open nasal passageways. Never underestimate the power of water!

Tamiflu 

Tamiflu is recommended for certain high risk people who are exposed to or sick with influenza. Prophylaxis can be given to prevent illness in children over 1 year of age who have known exposure within the past 48 hours if they meet high risk indications. Treatment of illness can be given to those over 2 weeks of age if they meet high risk criteria. There are shortages beginning this season and resistance can easily develop, so its use should be limited to those who truly need it.

High risks include: less than 2 years, lung disorders, immunologic disorders (immune compromised), chronic metabolic disease, and neuromuscular disorders.

If influenza symptoms have been present for more than 48 hours, it is not indicated unless there are special circumstances.

Tamiflu shortens the symptoms of influenza by 26 hours, about a day. It can help prevent the spread of the virus. It can have side effects, most commonly nausea and vomiting, but also more serious rashes and neurologic symptoms (confusion, delirium, and hallucinations).

Flu Vaccine

Vaccination is the best prevention against influenza. It does not make people get the flu. It is safe and indicated for everyone over 6 months of age. Thank you to all my patients who were vaccinated this year!  Although it is not 100% effective, it should lessen the risk of influenza to you.

Please don't wait to see if it will be a bad season before deciding if it's worth it to get the vaccine. Once the season has started it is less effective because it takes your body about 2 weeks to build immunity. Waiting also puts you at risk for being left out if there are shortages. Our office gave more vaccine than ever this year, but we still ran out earlier than ever this year.

If your family still needs the vaccine, check your local health department and pharmacies.  When we start vaccinating again this summer for next season, be sure to get your family vaccinated! (We will publicize availability on our website, Facebook page, and by email to those registered on our website.)

Vomiting and/or diarrhea

Vomiting and diarrhea can result from many viruses, usually NOT influenza. Treat with an electrolyte solution (such as Pedialyte, Gatorade's G2 - less sugar than regular). Give small volumes frequently. When kids get thirsty, they might gulp and then vomit, so put only 1 teaspoon in a small cup or syringe, or give a popsicle made of the electrolyte solution. Juice, carbonated lemon/lime drinks, and other high sugar drinks should be avoided.

Dairy increases stomach upset, and I generally say to avoid all milk products (except human milk) for 48 hours after the last vomiting or diarrhea. Breast milk can sometimes be tolerated, but it must be given slowly too, so often breast feeding should be stopped. Pump and give the expressed milk by the teaspoon in a syringe.

It's All In Your Perspective: Read Critically

As a mother of two middle schoolers, I know that school attempts to teach kids to read critically, but I don't think the population as a whole really catches on.

Headlines amaze me. I know they are trying to sell a newspaper or become the # 1 rated program on tv, but they spin stories so much it is sad. More than sad. They take advantage of our gullibility. They enrage people or get them riled up and then people share misinformation. This has happened time and again with many health issues. Just watch Oprah or Dr Oz. (For those who trust Dr Oz, see the bottom for links expressing my concerns.)

Recently some parents (more than one family, don't think I am singling anyone out here) have read a recent headline and want to stop a lifesaving drug for their children. No joke. They worry more about the drug that their child is thriving on because of one headline.

Asthma drug may stunt growth permanently is the title of a NBC News story.  Makes you think the poor asthmatic kids will never be able to perform in life because they are too short. Personally I would rather my child breathe comfortably while running, playing, and living regardless of how tall he/she will be, but really you need to look more closely than the title. (And many people only read headlines, so wouldn't read that the total difference was 1 cm = 1/2 inch. Not 1/2 foot or anything that really is significant in my humble opinion. Few jobs will require another 1/2 inch of height.)

Medscape is an online medical journal I follow. The title of their story about the same research: Pediatric Corticosteroids Have Minimal Effect on Adult Height.  If you are a headline reader, you will have a much different opinion about this life-saving asthma prevention medicine.

No wonder sometimes parents worry so much about things that we as physicians seem to "ignore" or not understand your concerns. We aren't concerned based on the way we have interpreted the research. Hopefully we can explain why we are not concerned, but often times emotions scream louder than statistical analysis information. I have blogged on this before in Decisions Parents Make: Use all the facts.

Please read information critically on your own. Think over what you read. Get additional information from other sources if it is a big issue to you. Think some more. Then make a decision you can stand firm in and not regret. Please.

For more:
Science-Based Medicine's blog: For shame, Dr. Oz, for promoting Joseph Mercola on your show! and Dr. Oz promotes quackery... again