How to manage a barking cough in a pediatric patient?

Management of Barking Cough in a 9-Year-Old

Administer a single dose of oral dexamethasone 0.15-0.60 mg/kg (typically 0.6 mg/kg) immediately, as this is the primary evidence-based treatment for croup regardless of severity. 1, 2

Immediate Assessment and Treatment

Clinical Recognition

• A barking cough in a 9-year-old child is characteristic of croup (laryngotracheobronchitis), typically presenting with inspiratory stridor, hoarseness, and varying degrees of respiratory distress 3, 1
• Most croup cases are viral in origin, with parainfluenza virus types 1-3 being the most common causative agents 1

First-Line Treatment: Corticosteroids

• Give oral dexamethasone 0.15-0.60 mg/kg as a single dose immediately - this is recommended for all patients with croup, including those with mild disease 1, 2
• Oral administration is the preferred route over parenteral or nebulized forms 4
• The correct dosage is critical, as lower steroid doses have proven ineffective 2
• Onset of action is approximately 6 hours after administration 2

Severity-Based Management

• For mild croup (barking cough without stridor at rest): Dexamethasone alone is sufficient 1
• For moderate to severe croup (stridor at rest, respiratory distress): Add nebulized epinephrine (racemic or l-epinephrine) while waiting for steroids to take effect 4, 1, 2
• If epinephrine is administered, monitor the patient for at least 2 hours for potential rebound airway obstruction 2, 5

Important Clinical Pitfalls to Avoid

What NOT to Do

• Do not use humidified air or mist therapy - recent studies show it provides no additional symptom improvement and does not alter the disease process 4, 1
• Do not use over-the-counter cough and cold medications, as they lack proven efficacy and carry potential safety concerns 6
• Do not withhold dexamethasone even in mild cases - a single dose is recommended for all severity levels 1

Critical Differential Diagnoses to Exclude

• Consider bacterial tracheitis, epiglottitis, foreign body aspiration, peritonsillar abscess, retropharyngeal abscess, and angioedema in the differential 1, 5
• Foreign body aspiration should always be considered, as it can present with chronic cough and a history of choking may be unwitnessed 7
• A normal chest radiograph does not exclude foreign body inhalation 7

Disposition and Follow-Up

Admission Criteria

• Admit if the child has stridor at rest, evidence of exhaustion, toxicity, or respiratory distress 5
• Only 1-8% of croup patients require hospital admission, and less than 3% of admitted patients require intubation 1

Recurrent Croup Considerations

• If this 9-year-old has experienced more than 2-3 episodes of croup, consider this recurrent croup 3
• For recurrent croup (>5 episodes), prophylactic inhaled corticosteroids initiated at the first sign of viral upper respiratory infection symptoms show promise in reducing frequency and severity of episodes 3
• Patients with >5 episodes are significantly more likely to improve with prophylactic inhaled corticosteroids compared to those with <5 episodes (p = 0.003) 3

Expected Clinical Course

• In most children, symptoms subside quickly with resolution of the cough within 2 days 1
• If cough persists beyond 4 weeks, transition to chronic cough evaluation protocols with chest radiograph and spirometry 8, 9