What is the recommended dose of Dexamethasone and home care considerations for a 2-year-old, 14kg child with croup, laryngitis, and probable pleurisy?

Dexamethasone Dosing and Management for Croup in a 2-Year-Old Child

Administer dexamethasone 0.6 mg/kg (8.4 mg for this 14 kg child) as a single oral dose immediately. This is the standard, evidence-based dose for moderate-to-severe croup that has been consistently shown to reduce symptoms, hospitalizations, and need for additional treatments 1, 2, 3, 4.

Dexamethasone Dosing Specifics

• The 0.6 mg/kg dose is superior to lower doses for moderate-to-severe croup, particularly at 24 hours post-administration, though 0.15 mg/kg may work for milder disease 3.
• Oral administration is preferred over intramuscular unless the child is vomiting or in severe respiratory distress and unable to tolerate oral medication 4.
• Onset of action begins at 30 minutes with statistically significant improvement, contrary to older literature suggesting 4-6 hours 5.
• Maximum single dose is 10-12 mg for larger children 4.
• The effect is sustained, reducing return visits and readmissions by approximately 45% compared to no treatment 3.

Critical Immediate Considerations

Assess for severe airway obstruction requiring nebulized epinephrine:

• Administer racemic epinephrine 0.5 mL/kg of 1:1000 solution (maximum 5 mL) via nebulizer if the child has significant stridor at rest, retractions, or difficulty breathing 6.
• Alternative: L-epinephrine (standard epinephrine) 0.5 mL/kg of 1:1000 solution up to 5 mL can be substituted if racemic epinephrine is unavailable 6.
• Monitor for 2 hours after epinephrine administration due to risk of rebound airway obstruction 1, 2.
• If two epinephrine treatments are required, hospitalize the child 2.

Rule out life-threatening differential diagnoses:

• Epiglottitis: Look for toxic appearance, drooling, tripod positioning, high fever (>102-103°F), and absence of barking cough 1.
• Retropharyngeal abscess: Check for neck stiffness, difficulty swallowing, and unilateral symptoms 1.
• Foreign body aspiration: Sudden onset without prodromal upper respiratory infection symptoms.

Pleurisy Consideration

The "probable pleurisy" mentioned is concerning and atypical for uncomplicated croup:

• Croup is an upper airway disease (laryngotracheobronchitis) and should not cause pleurisy 1.
• Pleuritic chest pain with coughing suggests lower respiratory tract involvement, possibly pneumonia or another concurrent infection 6.
• Obtain chest radiography if pleurisy is genuinely suspected, as this would change management significantly 6.
• If pneumonia is confirmed, consider adding antibiotics: amoxicillin 45-90 mg/kg/day divided twice daily for 10 days 7.

Fever Management

Resume scheduled antipyretics:

• Ibuprofen 10 mg/kg every 6 hours (140 mg for this 14 kg child) [@general medicine knowledge@].
• Acetaminophen 15 mg/kg every 4-6 hours (210 mg for this 14 kg child) as alternative or in combination [@general medicine knowledge@].
• Current temperature of 99.2°F is acceptable, but maintaining comfort and preventing high fevers reduces metabolic demand and respiratory distress [@general medicine knowledge@].

Home Care Instructions

Provide specific discharge guidance if not requiring hospitalization:

• Maintain humidity at ≥50% in the child's room using a cool mist humidifier 1.
• Ensure adequate hydration: Encourage frequent small sips of fluids 2.
• Avoid agitation: Keep the child calm, as crying worsens airway obstruction [@general medicine knowledge@].
• Monitor for worsening: Return immediately if stridor worsens at rest, retractions increase, cyanosis develops, or the child cannot speak/drink [@general medicine knowledge@].
• Expect improvement within 6-12 hours of dexamethasone administration, with peak effect at 24 hours 3.
• Antihistamines, decongestants, and antibiotics have no role in uncomplicated viral croup 2.

Observation Period

Observe for at least 2-4 hours after dexamethasone administration:

• If epinephrine was given, observe for minimum 2 hours to monitor for rebound obstruction 1, 2.
• Discharge is appropriate if the child shows improvement, has no stridor at rest, and parents are comfortable with home care 2.
• Hospitalize if: Two epinephrine treatments needed, persistent stridor at rest after treatment, hypoxemia, or inability to maintain hydration 2.

Respiratory Viral Panel (RVP) Consideration

The throat swab for RVP will not change acute management:

• Croup is typically caused by parainfluenza virus, but identification does not alter treatment 1.
• Results may guide infection control measures and provide prognostic information [@general medicine knowledge@].
• Do not delay dexamethasone administration while awaiting results [@general medicine knowledge@].