What is the treatment for a 5-year-old child presenting with a barky cough?

Treatment of Barky Cough in a 5-Year-Old Child

A barky cough in a 5-year-old child is croup until proven otherwise, and should be treated with a single dose of oral dexamethasone (0.15-0.60 mg/kg) regardless of severity, with nebulized epinephrine added for moderate to severe cases showing stridor at rest or respiratory distress. 1, 2, 3

Initial Assessment

Evaluate the severity of respiratory distress by assessing for:

• Stridor at rest (indicates moderate to severe disease requiring nebulized epinephrine) 1, 4
• Oxygen saturation (admission indicated if <92-94%) 5, 1
• Respiratory rate (>50 breaths/min in older children suggests need for admission) 5
• Work of breathing (chest retractions, nasal flaring, agitation from hypoxia) 5, 4
• Ability to maintain hydration and family's capacity to monitor at home 5, 1

The classic presentation includes a barking or brassy cough, inspiratory stridor, hoarseness, and low-grade fever following upper respiratory symptoms. 5, 2, 6, 3

Treatment Algorithm

All Cases (Mild to Severe)

Administer dexamethasone 0.15-0.60 mg/kg orally as a single dose. This is recommended for all children with croup, including mild cases, as it improves symptoms and reduces return visits and hospitalization. 1, 2, 3

Moderate to Severe Cases (Stridor at Rest or Respiratory Distress)

Add nebulized epinephrine 0.5 ml/kg of 1:1000 solution (racemic epinephrine). 1, 4

• The effect lasts only 1-2 hours, so observe for at least 2 hours after the last dose to assess for rebound symptoms before discharge. 1
• Do not use nebulized epinephrine in outpatient settings or shortly before discharge due to risk of rebound. 1
• If three doses of racemic epinephrine are needed, admit to hospital. 1

Oxygen Therapy

Administer oxygen to maintain saturation ≥94% using nasal cannulae, head box, or face mask. 5, 1

Important Considerations and Pitfalls

Avoid These Common Errors:

• Do not perform radiographic studies unless concerned about alternative diagnoses (bacterial tracheitis, foreign body aspiration, epiglottitis). 1, 2
• Do not use humidified air therapy - it has not been proven beneficial. 1, 2
• Do not perform chest physiotherapy - it is not beneficial in respiratory illness. 5
• Agitation may indicate hypoxia, not anxiety - treat with oxygen, not sedation. 5, 1

Alternative Diagnoses to Consider:

If the presentation is atypical, consider:

• Bacterial tracheitis (toxic appearance, high fever) 1, 2
• Foreign body aspiration (sudden onset without viral prodrome, unilateral findings) 1, 2
• Epiglottitis (drooling, tripod positioning, toxic appearance) 2, 4
• Pertussis (if paroxysmal cough with post-tussive vomiting or inspiratory whoop) 7

Recurrent Croup

If the child has had two or more episodes per year, this suggests an underlying structural or inflammatory airway abnormality (such as subglottic stenosis or tracheomalacia) and warrants referral to pediatric pulmonology or otolaryngology for further evaluation. 6

Disposition

Discharge Home If:

• No stridor at rest after treatment
• Oxygen saturation ≥94% on room air
• Adequate hydration
• Family able to monitor and return if worsening 1

Instruct families to return if: deterioration occurs or no improvement after 48 hours. 5

Admit to Hospital If:

• Three or more doses of racemic epinephrine required 1
• Oxygen saturation <92-94% 5, 1
• Stridor at rest despite treatment 1, 4
• Respiratory rate >50-70 breaths/min 5
• Signs of exhaustion or inability to maintain hydration 5, 4
• Age <18 months with moderate-severe symptoms 1