What is the initial treatment for a 2-year-old who is hemodynamically stable, oxygenating well, with watery nasal discharge, exhibiting a barking cough, stridor (stridor) with activity, and a hoarse voice, with no drooling or sinusosis (sinusitis)?

From the Guidelines

The initial treatment for this 2-year-old child with symptoms consistent with viral croup (laryngotracheobronchitis) should be a single dose of oral dexamethasone at 0.6 mg/kg (maximum 10 mg). This glucocorticoid helps reduce airway inflammation and swelling, typically improving symptoms within 2-6 hours and lasting for up to 72 hours 1. For a child who is stable and oxygenating well, home management is appropriate after treatment. Parents should be advised to keep the child calm, as agitation can worsen stridor, and to use cool mist humidification which may provide symptomatic relief.

Key Considerations

• The clinical presentation of barking cough, stridor with activity, and hoarse voice without drooling or signs of bacterial infection is classic for viral croup, which is typically caused by parainfluenza virus and is self-limiting, with most children improving within 3-5 days.
• Although infantile hemangioma (IH) can cause similar symptoms, the age of the child and the absence of other signs of IH, such as cutaneous lesions, make this diagnosis less likely 1.
• If stridor occurs at rest or respiratory distress develops, nebulized epinephrine (racemic epinephrine 2.25% solution, 0.5 mL in 2.5 mL normal saline, or L-epinephrine 1:1000,5 mL) should be administered in an emergency setting, followed by observation for at least 2-3 hours due to potential symptom rebound.

Treatment Approach

• The use of propranolol for airway IH has been reported to be effective, but this is not the primary diagnosis in this case, and dexamethasone is the preferred initial treatment for viral croup 1.
• Close monitoring of the child's symptoms and oxygen saturation is essential, and hospitalization may be necessary if the child's condition worsens or if there are concerns about airway obstruction.

From the Research

Initial Treatment for Croup in a 2-year-old

The initial treatment for a 2-year-old who is hemodynamically stable, oxygenating well, with watery nasal discharge, exhibiting a barking cough, stridor with activity, and a hoarse voice, with no drooling or sinusosis, can be outlined as follows:

• For mild to moderate croup, administration of prednisolone 1.0 mg/kg and review in 1 hour is recommended 2.
• Maintaining at least 50% relative humidity in the child's room is suggested 3.
• If there is evidence of hypoxemia, a mist tent with supplemental oxygen may be helpful 3.
• Racemic epinephrine administered by nebulizer can quickly reverse airway obstruction in children with croup, but the patient needs to be monitored for rebound airway obstruction for at least 2 hours after administration 3.
• Dexamethasone, administered 0.6 mg/kg, intramuscularly (IM), is the mainstay of treatment for severe croup, but its onset of action is approximately 6 hours after administration 3.
• The use of corticosteroids and a single dose of racemic epinephrine (RE) can be effective in treating croup, and emergency department discharge is safe when croup-related stridor has resolved 4.

Considerations for Treatment

It is essential to assess the airway, breathing, and circulation, focusing on the airway, when treating croup 2. The introduction of steroids in the treatment of croup has seen a significant reduction in hospital admissions and improved outcomes for children 2. Current treatment regimens for infectious croup involve various combinations of mist therapy, racemic epinephrine, corticosteroids, and other treatments, but tradition rather than science appears to be the basis of many of these treatments 5.