What are the treatment options for a child with a barking cough, likely indicative of croup?

Treatment Options for a Child with Barking Cough (Croup)

A child with a barking cough (croup) should be treated with a single dose of oral dexamethasone (0.6 mg/kg) regardless of disease severity, and nebulized epinephrine should be added for moderate to severe cases with respiratory distress. 1, 2

Diagnosis and Assessment

When evaluating a child with a barking cough, consider the following:

• Croup typically presents with a characteristic "barking seal" cough, inspiratory stridor, and hoarseness following upper respiratory symptoms 3
• The severity assessment should focus on:
  • Respiratory rate (>50 breaths/min indicates severe disease) 4
  • Presence of stridor at rest
  • Use of accessory muscles
  • Oxygen saturation (<92% indicates severe disease) 4
  • Level of alertness/agitation

Treatment Algorithm Based on Severity

Mild Croup (barking cough without stridor at rest)

• Single dose of oral dexamethasone 0.6 mg/kg 2, 1
• Home care with adequate hydration
• No need for nebulized epinephrine
• Reassurance to parents

Moderate to Severe Croup (stridor at rest, respiratory distress)

1. Single dose of oral dexamethasone 0.6 mg/kg 2, 1
2. Nebulized epinephrine (racemic epinephrine 2.25%, 0.5 mL diluted in 2.5 mL saline) 4, 2
3. Monitor for at least 2 hours after epinephrine administration for rebound symptoms 2
4. Humidified oxygen if oxygen saturation is ≤92% 4

Important Considerations

• Avoid over-the-counter cough medications, especially in children under 4 years, as they have minimal efficacy and potential for harm 4, 2
• Humidification therapy has not been proven beneficial despite common practice 5
• Honey (10mL mixed with warm water or milk) can be given to children over 1 year of age for symptomatic relief 2
• Antihistamines, decongestants, and antibiotics have no proven effect on uncomplicated viral croup 6

Hospitalization Criteria

Consider hospitalization if:

• Child requires two or more epinephrine treatments 6
• Persistent stridor at rest despite treatment
• Oxygen saturation ≤92% requiring supplemental oxygen 4, 2
• Inability to maintain oral hydration
• Significant respiratory distress or fatigue
• Inadequate home care or difficulty accessing medical care 2

Follow-up and Parent Education

• Most cases of croup resolve within 48 hours 5
• Parents should be advised to seek immediate medical attention if:
  • Child develops increasing respiratory distress
  • Child appears fatigued or lethargic
  • Child is unable to drink fluids
  • Symptoms worsen despite treatment

Common Pitfalls to Avoid

1. Delaying corticosteroid administration - Even mild cases benefit from dexamethasone 7
2. Overreliance on humidified air - This traditional therapy has not been proven effective 5
3. Failure to observe after epinephrine - Children should be monitored for at least 2 hours after administration due to risk of rebound symptoms 2
4. Missing alternative diagnoses - Consider bacterial tracheitis, epiglottitis, foreign body aspiration, or peritonsillar abscess in atypical or severe presentations 5

Croup is generally a self-limiting condition with excellent outcomes when properly managed with corticosteroids, with only 1-8% of patients requiring hospitalization and less than 3% of hospitalized patients needing intubation 5.