What is the appropriate management for an 18-month-old child with croup, presenting with a barking cough, mild inspiratory stridor, low-grade fever, and hypoxemia?

Management of Croup in an 18-Month-Old Child

Oral corticosteroids should be administered immediately to this 18-month-old child with croup, along with oxygen therapy to maintain saturation above 94% and consideration of nebulized epinephrine due to the presence of stridor. 1

Diagnosis

• The clinical presentation of barking cough, mild inspiratory stridor, low-grade fever, and nocturnal worsening is characteristic of viral croup 1, 2
• Radiographic studies are generally unnecessary and should be avoided unless there is concern for an alternative diagnosis 1
• Oxygen saturation of 93% indicates hypoxemia, which is an indicator for hospital admission in infants 3

Initial Management

Oxygen Therapy

• Administer oxygen via nasal cannulae, head box, or face mask to maintain oxygen saturation above 94% 3, 1
• Agitation may be an indication that the child is hypoxic and requires oxygen 3

Medication

• Oral corticosteroids are recommended for all cases of croup regardless of severity 1, 4

  • Dexamethasone 0.15-0.6 mg/kg as a single oral dose is the mainstay of treatment 1, 4
  • If oral administration is not tolerated, nebulized budesonide (2 mg) can be used as an alternative 4

• For moderate cases with stridor at rest or respiratory distress:

  • Nebulized epinephrine (0.5 ml/kg of 1:1000 solution) should be administered 1
  • The effect of nebulized epinephrine is short-lived (1-2 hours), requiring monitoring for rebound symptoms 1
  • Monitor the patient for at least 2 hours after the last dose of nebulized epinephrine 1

Hospitalization Criteria

• Consider hospital admission based on:
  • Oxygen saturation <92% (current saturation is 93%) 3, 1
  • Need for three or more doses of racemic epinephrine 1
  • Age <18 months (this patient is 18 months) 3
  • Respiratory rate >70 breaths/min 3
  • Difficulty in breathing or intermittent apnea 3

Important Considerations

• Current evidence does not support the use of humidified air or cold air exposure for symptom relief 1, 5
• Chest physiotherapy is not beneficial and should not be performed 3
• Antipyretics can be used to keep the child comfortable and help with coughing 3
• Minimal handling may reduce metabolic and oxygen requirements in ill children 3
• Monitor oxygen saturation at least every 4 hours for patients on oxygen therapy 3

Differential Diagnoses to Consider

• Bacterial tracheitis 1, 6
• Foreign body aspiration 1, 6
• Epiglottitis 6
• Pertussis (especially with post-tussive vomiting) 7

Follow-up Recommendations

• If discharged home, the child should be reviewed by a general practitioner if deteriorating or not improving after 48 hours 3
• Provide families with information on managing fever, preventing dehydration, and identifying signs of deterioration 3
• Consider pertussis testing if symptoms persist or post-tussive vomiting develops 7

Common Pitfalls to Avoid

• Do not rely on humidification therapy as it has not been proven beneficial 6
• Avoid nebulized epinephrine in children who are shortly to be discharged due to risk of rebound symptoms 1
• Do not perform blind finger sweeps if foreign body aspiration is suspected 1
• Avoid empirical treatment approaches for conditions like asthma unless other features consistent with these conditions are present 3, 7