What are the treatment options for a 6-month-old with a croupy cough in the Emergency Department (ED)?

Treatment of Croupy Cough in a 6-Month-Old in the Emergency Department

For a 6-month-old with croupy cough in the ED, immediate administration of oral dexamethasone (0.15-0.60 mg/kg) is recommended as first-line treatment, with nebulized epinephrine (0.5 ml/kg of 1:1000 solution) for moderate to severe cases. 1

Assessment and Severity Scoring

• Use the Westley Croup Score to determine severity:

  • Stridor (0-3 points): None, when agitated, at rest
  • Retractions (0-3 points): None, mild, moderate, severe
  • Air entry (0-3 points): Normal, decreased, markedly decreased
  • Cyanosis (0-4 points): None, with agitation, at rest
  • Level of consciousness (0-5 points): Normal, altered

• Severity classification:

  • Mild: Score 0-2
  • Moderate: Score 3-5
  • Severe: Score 6-11
  • Impending respiratory failure: Score ≥12

Treatment Algorithm

For All Severity Levels:

1. Administer dexamethasone 0.15-0.60 mg/kg orally as a single dose 1
   • Onset of action begins as early as 30 minutes, with full effect at 6 hours 2
   • Even mild cases benefit from steroid treatment 3

For Moderate to Severe Cases (Westley Score ≥3):

1. Add nebulized epinephrine (0.5 ml/kg of 1:1000 solution) 1
2. Monitor for at least 2-3 hours after epinephrine administration to watch for rebound symptoms 1, 4
3. Provide supplemental oxygen if saturation is <92% 1

For Severe Cases with Respiratory Distress:

1. Consider simultaneous administration of corticosteroid and epinephrine to reduce intubation risk 1
2. Consider heliox for reducing work of breathing in severe upper airway obstruction 1

Monitoring Requirements

• Continuous oxygen saturation monitoring for moderate to severe cases
• Close observation of:
  • Respiratory rate
  • Work of breathing
  • Level of consciousness
  • Ability to maintain hydration

Discharge Criteria

A 6-month-old with croup can be safely discharged when:

• No stridor at rest persists after treatment
• Oxygen saturation remains ≥92% on room air
• Child can tolerate oral fluids
• No repeated doses of epinephrine are required
• Parents understand home care instructions 1

Hospital Admission Criteria

Consider hospital admission if any of the following are present:

• Oxygen saturation <92% or cyanosis
• Persistent significant respiratory distress after treatment
• Stridor at rest that persists after treatment
• Need for more than one dose of nebulized epinephrine
• Inability to tolerate oral fluids
• Toxic appearance 1, 5

Important Considerations

• Maintain a calm environment to reduce agitation which can worsen symptoms
• Ensure adequate hydration
• Avoid antihistamines, decongestants, and antibiotics as they have no proven effect on viral croup 6
• Consider differential diagnoses including epiglottitis, foreign body aspiration, retropharyngeal abscess, bacterial tracheitis, and congenital anomalies 1, 3

Home Care Instructions (if discharged)

• Maintain adequate hydration
• Use cool mist humidification (though evidence for benefit is limited) 3, 7
• Control fever with appropriate antipyretics
• Return to ED if increased work of breathing, lethargy, or inability to drink fluids

By following this evidence-based approach, most 6-month-olds with croupy cough can be effectively managed in the ED, with only 1-8% requiring hospital admission 3.