What is the appropriate management for a 4-year-old presenting with fever and a barky cough, suggestive of croup?

Management of a 4-Year-Old with Fever and Barky Cough (Croup)

A 4-year-old with fever and barky cough should be treated with a single dose of oral dexamethasone (0.15-0.60 mg/kg) regardless of symptom severity, and nebulized epinephrine should be added for moderate to severe symptoms with respiratory distress. 1

Assessment Questions for SOAP Note

Subjective (History)

• Duration and progression of symptoms
  • When did the cough start?
  • Has the cough worsened at night?
  • Any preceding upper respiratory symptoms (runny nose, congestion)?
• Fever details
  • How high is the fever? (>38.5°C warrants more concern)
  • How long has the fever been present? (>48 hours may indicate higher risk) 2
• Respiratory symptoms
  • Presence of stridor (especially inspiratory)
  • Hoarseness of voice
  • Difficulty breathing or rapid breathing
  • Retractions (suprasternal, intercostal)
  • Cyanosis
• Associated symptoms
  • Decreased oral intake or feeding difficulties
  • Lethargy or decreased activity
  • Drooling (concerning for epiglottitis)
• Past medical history
  • Previous episodes of croup or similar symptoms
  • History of asthma or reactive airway disease
  • Any congenital airway abnormalities
  • Immunization status

Objective (Physical Examination)

• Vital signs
  • Temperature (document exact value)
  • Respiratory rate (tachypnea is concerning: >50 breaths/min for a 4-year-old) 2
  • Heart rate (tachycardia out of proportion to fever suggests respiratory distress) 2
  • Oxygen saturation (should be >92%) 2
• General appearance
  • Level of alertness
  • Signs of respiratory distress
  • Positioning (tripod position suggests severe distress)
• Respiratory examination
  • Presence and severity of stridor
  • Quality of cough (barky/seal-like is characteristic of croup)
  • Presence of retractions
  • Lung auscultation for crackles/rales (may suggest pneumonia) 2
  • Air entry
• ENT examination
  • Throat examination (avoid if epiglottitis suspected)
  • Presence of nasal discharge

Assessment and Plan

Assessment

• Likely diagnosis: Viral croup (laryngotracheobronchitis)
  • Most common in children 6 months to 3 years of age 1
  • Characterized by barky cough, inspiratory stridor, and hoarseness 1
  • Usually preceded by upper respiratory symptoms 3

Severity Assessment

• Mild: Barky cough, no audible stridor at rest, minimal retractions
• Moderate: Barky cough, audible stridor at rest, retractions, but no distress
• Severe: Barky cough, prominent stridor, marked retractions, signs of fatigue/distress

Plan

Treatment

1. Medications:

   • Dexamethasone 0.15-0.60 mg/kg as a single oral dose (recommended for ALL severity levels) 1
   • For moderate to severe symptoms: Add nebulized epinephrine (racemic or L-epinephrine) 1, 4
   • Monitor for at least 2 hours after epinephrine administration to watch for rebound symptoms 3

2. Supportive care:

   • Maintain hydration
   • Antipyretics for fever management
   • Calm environment (agitation can worsen symptoms) 2

Home Care Instructions

• Fever management with appropriate antipyretics
• Adequate fluid intake to prevent dehydration 2
• When to return to medical care:
  • Increased work of breathing
  • Inability to drink fluids
  • Worsening symptoms despite treatment
  • Lethargy or decreased responsiveness

Follow-up

• Return for evaluation if symptoms persist beyond 48 hours or worsen 2
• Most croup symptoms improve within 2 days 5

Red Flags Requiring Immediate Attention

• Oxygen saturation <92% 2
• Severe respiratory distress with marked retractions
• Altered mental status or lethargy
• Inability to maintain hydration
• Cyanosis
• Drooling or inability to swallow (suggests possible epiglottitis)
• Toxic appearance

Differential Diagnosis to Consider

• Bacterial tracheitis
• Epiglottitis (less common since Hib vaccination)
• Foreign body aspiration
• Peritonsillar or retropharyngeal abscess
• Angioedema 5
• Recurrent croup (>2 episodes/year) may warrant investigation for underlying structural abnormalities 6

Remember that while most croup cases are mild and self-limiting, proper assessment and timely intervention with dexamethasone can significantly reduce symptoms, prevent return visits, and decrease hospitalization rates.