What is the best course of treatment for a pediatric patient under 5 years old with a history of respiratory infections presenting with a barking cough?

Management of Barking Cough in Pediatric Patients Under 5 Years

Immediate Diagnosis and Treatment

A barking cough in a pediatric patient under 5 years with a history of respiratory infections is croup until proven otherwise, and you should immediately administer oral dexamethasone 0.15-0.60 mg/kg (maximum 10 mg) regardless of severity. 1

Initial Assessment

Evaluate the child immediately for severity indicators that determine your next steps: 1

• Stridor at rest - indicates moderate to severe disease requiring nebulized epinephrine 1
• Respiratory rate - >70 breaths/min in infants or >50 breaths/min in older children signals severe distress 2
• Use of accessory muscles - indicates significant respiratory compromise 1
• Oxygen saturation - <92-94% requires oxygen therapy and hospitalization 1, 2
• Ability to speak/cry normally - loss of voice or weak cry suggests severe obstruction 1

Treatment Algorithm

For all cases (mild, moderate, severe):

• Give oral dexamethasone 0.15-0.60 mg/kg as a single dose (maximum 10 mg) immediately 1, 3, 4
• If dexamethasone is unavailable, use prednisolone 1-2 mg/kg (maximum 40 mg) 1

For moderate to severe cases (stridor at rest or respiratory distress):

• Add nebulized epinephrine 0.5 ml/kg of 1:1000 solution 1
• Critical pitfall: The effect lasts only 1-2 hours, so you must observe the patient for at least 2 hours after the last epinephrine dose to watch for rebound symptoms 1
• Never discharge within 2 hours of epinephrine administration 1
• Never use nebulized epinephrine in outpatient settings where immediate return is not feasible 1

For severe cases with hypoxemia:

• Administer oxygen to maintain saturation ≥94% using nasal cannula, head box, or face mask 1, 2
• Position child in neutral head position with roll under shoulders (under 2 years) to optimize airway patency 1

Hospitalization Criteria

Admit the patient if: 1, 2

• Three or more doses of racemic epinephrine are required 1
• Oxygen saturation <92% 2
• Age <18 months with significant symptoms 2
• Respiratory rate >70 breaths/min 2
• Family unable to provide appropriate observation or return if worsening 1

Evidence note: Recent guidelines show that limiting admission until 3 doses of racemic epinephrine are needed reduces hospitalization by 37% without increasing revisits or readmissions 1

Critical Differential Diagnoses to Exclude

Before finalizing croup diagnosis, actively rule out: 1, 4

• Bacterial tracheitis - toxic appearance, high fever, rapid deterioration 1
• Foreign body aspiration - sudden onset without viral prodrome, unilateral findings 1
• Epiglottitis - drooling, tripod positioning, toxic appearance 4
• Retropharyngeal or peritonsillar abscess - severe dysphagia, neck stiffness 4

Never perform blind finger sweeps if foreign body is suspected, as this pushes objects deeper into the pharynx 1

What NOT to Do

• Do not obtain radiographs unless you suspect an alternative diagnosis - clinical assessment is sufficient for croup 1
• Do not use humidified or cold air - current evidence shows no benefit 1
• Do not prescribe over-the-counter cough and cold medications in children under 2 years due to lack of efficacy and risk of serious toxicity including fatalities 2
• Do not use chest physiotherapy - it provides no benefit 2
• Do not use topical decongestants in children under 1 year due to narrow therapeutic window and cardiovascular/CNS toxicity risk 2

Follow-Up and Recurrent Episodes

If the child has had two or more episodes of croup per year, consider: 5, 1

• Asthma - especially if cough worsens at night, triggered by exercise/irritants, or family history of atopy 1
• Anatomic airway abnormality - requires flexible bronchoscopy if severe, persistent, or atypical presentation 1
• Gastroesophageal reflux - if associated with vomiting or feeding difficulties 1

Discharge home only if: 1

• At least 2 hours have passed since last epinephrine dose without rebound symptoms 1
• Family is reliable and able to monitor and return if worsening 1
• Oxygen saturation remains ≥94% on room air 1

Instruct families to return immediately for: 2

• Worsening stridor or respiratory distress 2
• Inability to drink or signs of dehydration 2
• Cyanosis or extreme fatigue 2

Review by healthcare provider if not improving after 48 hours 2

Persistent Cough Beyond Acute Episode

If cough persists beyond 4 weeks after the acute episode, this becomes chronic cough requiring systematic evaluation: 6

• Obtain chest radiograph and spirometry 6
• Determine if cough is wet/productive (suggests protracted bacterial bronchitis) or dry (likely post-viral) 6
• For wet cough, prescribe 2-week course of antibiotics targeting Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis 6
• Do not empirically treat for asthma unless other features consistent with asthma are present 7, 6