Treatment of Inspiratory Stridor and Barking Cough in Children Under 2 Years
All children under 2 years presenting with inspiratory stridor and barking cough should receive a single dose of oral dexamethasone 0.15-0.60 mg/kg (maximum 10 mg) immediately, with nebulized epinephrine (0.5 ml/kg of 1:1000 solution) added for moderate-to-severe cases showing stridor at rest or respiratory distress. 1
Initial Clinical Assessment
Evaluate severity immediately by assessing:
- Ability to cry normally - inability suggests severe obstruction 1
- Respiratory rate and use of accessory muscles (tracheal tug, retractions) 1, 2
- Presence of stridor at rest versus only with agitation 1
- Oxygen saturation - levels <92-94% indicate need for supplemental oxygen and hospitalization 1
- Life-threatening signs: silent chest, cyanosis, fatigue/exhaustion, poor respiratory effort 1
The clinical presentation described (inspiratory stridor + barking cough in a child <2 years) is pathognomonic for viral croup, which accounts for the most common cause of acute upper airway obstruction in this age group. 3, 4, 5
Immediate Treatment Algorithm
All Severity Levels:
Administer oral dexamethasone immediately - 0.15-0.60 mg/kg as a single dose (maximum 10 mg). 1, 6 If oral administration is not possible, use intramuscular dexamethasone 0.6 mg/kg. 4 The onset of action is approximately 6 hours, but benefits include decreased symptoms, reduced hospitalization rates, and shorter hospital stays. 6, 5
Moderate-to-Severe Cases (stridor at rest, respiratory distress):
Add nebulized epinephrine - 0.5 ml/kg of 1:1000 solution. 1 This provides rapid but temporary relief lasting only 1-2 hours. 7, 1
Critical pitfall: Never discharge within 2 hours of epinephrine administration due to risk of rebound symptoms. 1 The child must be observed for at least 2 hours after the last epinephrine dose. 1
Oxygen Support:
Administer supplemental oxygen to maintain saturation ≥94% using nasal cannula, head box, or face mask. 1 Position the child with a neutral head position and roll under shoulders to optimize airway patency. 1
Hospitalization Criteria
Admit to hospital if:
- Three or more doses of racemic epinephrine are required 1
- Oxygen saturation <92% 1
- Age <18 months with severe symptoms 1
- Respiratory rate >70 breaths/min 1
- Persistent respiratory distress despite treatment 1
Recent evidence shows limiting admission until 3 doses of epinephrine are needed reduces hospitalization by 37% without increasing adverse outcomes. 1
Differential Diagnoses to Exclude
While croup is most likely, immediately consider and exclude:
- Foreign body aspiration - sudden onset without prodrome, unilateral wheeze, history of choking episode 1, 3
- Bacterial tracheitis - toxic appearance, high fever, rapid deterioration 1, 3
- Epiglottitis - drooling, tripod positioning, toxic appearance (rare post-Hib vaccine) 3, 5
- Retropharyngeal abscess - neck stiffness, dysphagia, muffled voice 1
Important: Never perform blind finger sweeps if foreign body is suspected, as this may push objects deeper. 1
When to Perform Flexible Bronchoscopy
Bronchoscopy is not indicated for typical croup but should be performed if: 7
- Severe or persistent symptoms not responding to standard treatment 7
- Associated hoarseness suggesting vocal cord pathology 7
- Oxygen desaturation or apnea 7
- Atypical presentation raising concern for anatomic abnormality 7
In infants with stridor, laryngomalacia is the most common congenital cause, but up to 68% have concomitant lower airway abnormalities requiring complete airway evaluation. 7
Therapies to Avoid
- Humidified or heated air - no proven benefit 1
- Chest physiotherapy - not beneficial 1
- Empirical asthma medications - unless other features of asthma present 1
- Radiographic studies - unnecessary for typical croup, may delay treatment 1, 5
Discharge Instructions
If discharging home after observation: