What's the next step for a child with a persistent barky cough, consistent with croup, who remains symptomatic despite being treated with dexamethasone (a corticosteroid) a few days ago?

Persistent Barky Cough After Dexamethasone: Next Steps

For a child with persistent barky cough despite dexamethasone treatment a few days ago, reassess immediately for signs of respiratory distress (stridor at rest, increased work of breathing, oxygen saturation <94%), and if present, administer nebulized epinephrine 0.5 mL/kg of 1:1000 solution (maximum 5 mL) in a monitored setting, as this child may have moderate-to-severe croup requiring escalation of therapy. 1

Immediate Assessment Required

• Check for stridor at rest (not just with crying or agitation), increased work of breathing (retractions, nasal flaring), and oxygen saturation—maintain ≥94% 1
• Evaluate for signs of dehydration or fatigue, which indicate more severe disease 1
• Assess whether symptoms are worsening, stable, or improving since the initial dexamethasone dose, as persistent symptoms beyond 3-5 days warrant consideration of alternative diagnoses 1, 2

If Respiratory Distress is Present

• Administer nebulized epinephrine immediately at 0.5 mL/kg of 1:1000 solution (maximum 5 mL) by nebulizer 1
• Observe for at least 2-3 hours after epinephrine administration, as the effect is short-lived (1-2 hours) and rebound symptoms can occur 1
• Consider hospital admission if three or more doses of epinephrine are required, if respiratory distress persists despite treatment, or if oxygen is needed to maintain saturation ≥94% 1

If No Respiratory Distress But Persistent Barky Cough

• Consider a repeat dose of dexamethasone if the initial dose was given more than 24-48 hours ago and symptoms persist, though evidence for repeat dosing is limited 3
• Re-evaluate within 24 hours if symptoms persist without worsening 1, 2
• Provide supportive care: keep the child calm, avoid distress, ensure adequate hydration 2

Critical Pitfall: Rule Out Alternative Diagnoses

If symptoms worsen after initial improvement or persist beyond 5-7 days, prompt reassessment is necessary to rule out:

• Bacterial tracheitis (high fever, toxic appearance, purulent secretions) 1
• Foreign body aspiration (sudden onset, unilateral findings, no viral prodrome) 1
• Tracheomalacia (persistent barky cough without acute illness) 4
• Habit cough or psychogenic cough (honking quality, absence during sleep, no respiratory distress) 4

The barky cough characteristic can suggest croup, tracheomalacia, or habit cough, but is not diagnostic of any single condition 4. The clinical context—particularly the presence or absence of respiratory distress and the temporal pattern—is essential for distinguishing these entities.

What NOT to Do

• Do not use nebulized epinephrine in an outpatient setting or shortly before discharge due to risk of rebound symptoms 1, 2
• Do not use inhaled corticosteroids from hand-held inhalers with spacers, as they are not effective for croup 1, 2
• Do not use over-the-counter cough medications, as they have no benefit and may cause harm 5, 2
• Do not assume this is simply resolving croup if symptoms persist beyond 5-7 days without improvement 1

Dosing Considerations for Dexamethasone

The evidence supports that 0.15 mg/kg dexamethasone is as effective as 0.6 mg/kg for most cases of croup, with benefit evident as early as 30 minutes after administration 6, 7, 8, 3. If the child received an appropriate dose initially (0.15-0.6 mg/kg, maximum 10-12 mg), the persistence of symptoms suggests either:

1. More severe disease requiring additional therapy (epinephrine) 1, 9
2. An alternative or additional diagnosis beyond typical viral croup 1

When to Hospitalize

• Three or more doses of epinephrine required 1
• Persistent respiratory distress despite treatment 1
• Oxygen requirement to maintain saturation ≥94% 1
• Signs of impending respiratory failure (altered mental status, severe retractions, cyanosis) 1