A parent hands you a lethargic 22-month-old male and states "he's had a congested cough." He has sternal retractions and his belly and chest move in opposite directions with each breath. You should suspect what condition?

The situation described presents symptoms that are indicative of respiratory distress. The lethargy of the child, in combination with sternal retractions, suggests that the child is struggling to breathe effectively. Sternal retractions occur when the muscles between the ribs are working harder than normal to assist with breathing, a common sign of respiratory distress in children.

Additionally, the description of the belly and chest moving in opposite directions during breathing (a phenomenon known as "paradoxical breathing") indicates that the child is not utilizing normal respiratory mechanics, which can happen when there is significant respiratory compromise. This mechanical dysfunction often points towards a critical respiratory issue, further supporting the likelihood of respiratory distress.

While allergic reactions, breath-holding spells, and asthma attacks might present with some overlapping symptoms, the combination of lethargy, retractions, and the paradoxical movement clearly correlates with a significant respiratory issue. Thus, respiratory distress is the most appropriate condition to suspect in this scenario.