What is the treatment for a child with a barking cough?

Treatment of Barking Cough (Croup) in Children

A single dose of oral dexamethasone (0.15-0.60 mg/kg) should be given to all children with croup, including those with mild disease, as this is the evidence-based standard of care that reduces symptoms, hospitalizations, and duration of illness. 1, 2

Immediate Management Algorithm

First-Line Treatment for ALL Severity Levels

• Administer dexamethasone 0.15-0.60 mg/kg orally (single dose) to every child presenting with barking cough consistent with croup, regardless of severity 1, 2
• The oral route is preferred and equally effective as intramuscular administration 3
• Lower doses (0.15 mg/kg) appear to have similar efficacy to higher doses (0.6 mg/kg), making the lower dose reasonable for mild cases 2
• Onset of action is approximately 6 hours, so symptoms may not improve immediately 4

Additional Treatment for Moderate to Severe Croup

• Nebulized epinephrine (racemic or L-epinephrine) should be administered for children with stridor at rest, significant respiratory distress, or moderate to severe symptoms 1, 5, 3
• Epinephrine provides rapid symptom relief (within minutes) while waiting for dexamethasone to take effect 4
• Critical safety consideration: Observe the child for at least 2 hours after epinephrine administration due to risk of rebound airway obstruction 4

Treatments to AVOID

• Do NOT use humidification therapy (mist tents, humidified air) as it has not been proven beneficial in croup 1, 3
• Do NOT use over-the-counter cough medications as they are ineffective and potentially harmful in children 6
• Do NOT use antihistamines or dextromethorphan as they provide no benefit for cough relief 6
• Do NOT use honey in children under 12 months due to botulism risk 6

Clinical Assessment Points

Recognize the Classic Presentation

• Barking "seal-like" cough is the hallmark symptom 1, 5, 4
• Typically preceded by upper respiratory infection symptoms with low-grade fever and runny nose 1, 4
• Inspiratory stridor (harsh breathing sound) and hoarse voice are common 2, 5
• Most commonly affects children 6 months to 6 years of age 4
• Symptoms usually peak at night and often resolve within 2 days 1

Exclude Dangerous Mimics

• Always consider and rule out: bacterial tracheitis, epiglottitis, foreign body aspiration, peritonsillar abscess, retropharyngeal abscess, and angioedema 1
• These conditions require different management and can be life-threatening if missed 5

Disposition Criteria

Indications for Hospital Admission (1-8% of cases)

• Stridor at rest 5
• Signs of exhaustion or agitation 5
• Evidence of respiratory distress (retractions, tachypnea, hypoxia) 5
• Toxic appearance 5
• Less than 3% of admitted patients require intubation 1

Outpatient Management Appropriate When

• Mild symptoms without stridor at rest 1
• No respiratory distress 5
• Child able to maintain hydration and oxygenation 4
• Reliable caregivers with access to emergency care if worsening 4

Common Pitfalls to Avoid

• Withholding steroids in "mild" cases: Even mild croup benefits from dexamethasone, which reduces symptom duration and prevents progression 1, 2
• Discharging too soon after epinephrine: Must observe for minimum 2 hours due to rebound phenomenon 4
• Using ineffective humidity therapy: This wastes time and resources without providing benefit 1, 3
• Prescribing antibiotics: Croup is viral (most commonly parainfluenza virus types 1-3) and does not respond to antibiotics 1
• Underdosing steroids: Historical studies showed lower steroid doses were ineffective; use at least 0.15 mg/kg 4

Alternative Steroid Options

• Nebulized budesonide 2 mg has equivalent efficacy to oral dexamethasone and may be used if oral administration is not feasible 2, 3
• For severe croup requiring intubation, oral prednisolone 1 mg/kg every 12 hours decreases intubation duration 2