Treatment for a 2-Year-Old with Barking Cough and Stridor
For a 2-year-old presenting with barking cough and stridor, the first-line treatment is oral dexamethasone 0.15-0.60 mg/kg as a single dose, with nebulized epinephrine (0.5 ml/kg of 1:1000 solution) for moderate to severe cases. 1
Assessment and Diagnosis
Before initiating treatment, assess severity using the Westley Croup Score:
| Parameter | 0 points | 1 point | 2 points | 3 points | 4 points | 5 points |
|---|---|---|---|---|---|---|
| Stridor | None | When agitated | At rest | - | - | - |
| Retractions | None | Mild | Moderate | Severe | - | - |
| Air entry | Normal | Decreased | Markedly decreased | - | - | - |
| Cyanosis | None | - | - | With agitation | At rest | - |
| Level of consciousness | Normal | - | - | - | - | Altered |
The barking cough and stridor in this 2-year-old child are highly suggestive of croup (laryngotracheobronchitis), which is typically viral in origin 1, 2.
Treatment Algorithm
Mild Croup (Score 0-2)
- Dexamethasone 0.15-0.60 mg/kg orally as a single dose 1, 3
- Maintain calm environment
- Ensure adequate hydration
- Monitor for 2-3 hours to ensure no progression
- Can be managed at home if symptoms improve
Moderate Croup (Score 3-5)
- Dexamethasone 0.15-0.60 mg/kg orally as a single dose 1, 3
- Nebulized epinephrine 0.5 ml/kg of 1:1000 solution 1, 4
- High-flow oxygen if oxygen saturation <92% 1
- Monitor for at least 2-3 hours after epinephrine administration
- Consider hospitalization if more than one dose of epinephrine is needed
Severe Croup (Score 6-11)
- Immediate nebulized epinephrine 0.5 ml/kg of 1:1000 solution 1, 4
- Dexamethasone 0.6 mg/kg orally or parenterally 1, 3
- High-flow oxygen to maintain saturation >92% 1
- Consider adding ipratropium to nebulizer and repeat 6-hourly 5
- Hospitalization is indicated
- Prepare for possible airway intervention if deterioration occurs
Life-threatening Croup (Score ≥12)
- Immediate airway management
- Transfer to intensive care unit
- Consider intubation
- Consult ENT specialist
Monitoring and Follow-up
- Reassess croup score 15-30 minutes after initial treatment and regularly thereafter 1
- Monitor oxygen saturation continuously in moderate to severe cases
- Observe for at least 2-3 hours after nebulized epinephrine due to potential rebound symptoms 1
- If multiple doses of epinephrine are required, hospital admission is indicated 1
Important Considerations
- The effect of nebulized epinephrine is short-lived (1-2 hours), so observation for rebound symptoms is essential 1, 4
- Avoid routine imaging unless there is suspicion of an alternative diagnosis 1
- Dexamethasone has been shown to decrease symptoms and reduce hospitalization rates even in mild to moderate cases 3
- L-epinephrine and racemic epinephrine are equally effective 4
Discharge Criteria
- Significant improvement in symptoms (minimal or no stridor at rest)
- Able to tolerate oral fluids
- No need for repeated doses of epinephrine
- Parents educated about warning signs requiring return
- Follow-up arranged within 48 hours if symptoms persist 1
Cautions
- Avoid desflurane if anesthesia is required, as it may increase airway resistance in children with upper respiratory tract infections 5
- Differentiate from epiglottitis (which presents with dysphagia, drooling) and foreign body aspiration (sudden onset, no fever) 1
- Consider bacterial tracheitis if not responding to standard therapy 6
This approach prioritizes reducing morbidity and mortality while improving quality of life by promptly addressing respiratory distress and preventing progression to respiratory failure.