What should I do if my child has a barking cough and stridor but appears to be playing without distress?

Management of Barking Cough and Stridor in a Child Without Distress

Your son likely has mild croup, and since he is playing without distress, you should give him a single dose of oral corticosteroid (dexamethasone 0.6 mg/kg, maximum 10 mg) and monitor him at home for worsening symptoms. 1

Immediate Assessment

Your child's presentation is consistent with croup—the barking cough and stridor are classic features of upper airway inflammation. 2 The critical factor here is that he appears well and is playing, which indicates mild croup rather than moderate or severe disease. 1

Key Features to Monitor:

• Stridor at rest (the noisy breathing you hear when he's calm) versus stridor only with agitation or crying 1
• Work of breathing: Look for chest retractions (skin pulling in between ribs), nasal flaring, or rapid breathing 1
• Oxygen saturation: If available, should be ≥94% 1
• Agitation or lethargy: May indicate worsening hypoxia 1

Treatment Recommendations

For Your Child (Mild Croup):

Oral corticosteroids are recommended for all cases of croup, regardless of severity. 1 This single dose will:

• Reduce airway inflammation 3
• Decrease the likelihood of worsening symptoms 2
• Reduce the need for emergency department visits 2

Nebulized epinephrine is NOT needed for your child since he lacks respiratory distress and is playing normally. 1 This medication is reserved for moderate to severe cases with stridor at rest or significant respiratory distress. 1

What NOT to Do:

• Do not use humidified or cold air therapy—current evidence shows no benefit for croup symptoms 1, 3
• Do not give over-the-counter cough medications—these are ineffective and potentially harmful in young children 4
• Do not perform chest physiotherapy—this provides no benefit 1

When to Seek Emergency Care

You should take your son to the emergency department immediately if he develops:

• Stridor that worsens or becomes continuous at rest 1
• Increased work of breathing: chest retractions, nasal flaring, or breathing rate >70 breaths/min 1
• Agitation, lethargy, or difficulty staying awake (signs of hypoxia) 1
• Difficulty swallowing or drooling (may indicate epiglottitis, not croup) 2
• Oxygen saturation <92-94% if you have a home pulse oximeter 1

Important Caveats

Duration and Follow-up:

• Croup symptoms typically last 3-7 days 2
• If symptoms persist beyond 48 hours without improvement or worsen, have him evaluated by his pediatrician 1
• If he requires three doses of nebulized epinephrine in the emergency department, hospitalization would be indicated 1

Alternative Diagnoses to Consider:

While croup is most likely, be aware that stridor can also indicate:

• Foreign body aspiration: Would typically have sudden onset without preceding viral symptoms 1, 5
• Bacterial tracheitis: Would present with high fever and toxic appearance 1
• Epiglottitis: Would show drooling, difficulty swallowing, and preference for sitting upright 2

Recurrent Episodes:

If your son has two or more episodes of croup per year, this constitutes recurrent croup and should prompt evaluation for underlying structural airway abnormalities. 6 This would require referral to a pediatric pulmonologist or otolaryngologist for further workup.

Practical Home Management

• Keep him comfortable and minimize handling to reduce oxygen requirements 1
• Use antipyretics (acetaminophen or ibuprofen) if he has fever, which helps with comfort 1
• Ensure adequate hydration 1
• Monitor him closely, especially at night when symptoms often worsen 2

The key distinction is that your child is playing and not in distress—this indicates mild disease that can be safely managed at home with oral corticosteroids and close observation. 1