Can a 6-year-old child with fever and tachycardia presenting with a croup cough be given oral dexamethasone?

Yes, oral dexamethasone is indicated and should be given to this 6-year-old with croup

A single dose of oral dexamethasone 0.15-0.60 mg/kg should be administered to all children with croup, regardless of severity, including those with mild disease. 1 The presence of fever and tachycardia does not contraindicate dexamethasone use in croup.

Clinical Assessment of This Patient

This child presents with classic croup features:

• Characteristic barking/croup cough 1
• Fever of 102.9°F (39.4°C) - common in viral croup 1
• Heart rate 159 bpm - likely compensatory tachycardia from fever and respiratory effort

Evaluate for Severity and Need for Hospitalization

Before administering dexamethasone, assess for signs requiring immediate hospital referral 2:

• Respiratory distress signs: markedly raised respiratory rate (>50 breaths/min concerning), grunting, intercostal retractions, nasal flaring 3, 2
• Cyanosis 3
• Altered mental status or drowsiness 3
• Inability to maintain hydration 3
• Oxygen saturation <92% 2

If none of these severe features are present, the child can be treated at home with oral dexamethasone.

Dexamethasone Dosing and Administration

Recommended dose: 0.15-0.60 mg/kg orally as a single dose 1, 4

• 0.15 mg/kg is as effective as higher doses (0.3 or 0.6 mg/kg) for symptom relief and hospitalization duration 5
• Onset of action: Benefits evident by 30 minutes, with statistically significant improvement in croup scores 6
• Route: Oral administration is preferred and equally effective as intramuscular 7, 1

Evidence Supporting Use in All Severities

• Mild croup benefits significantly: In children with mild croup (Westley score ≤2), dexamethasone reduced return to medical care from 15.3% to 7.3% (P<0.001), with quicker symptom resolution and less sleep disruption 4
• Moderate to severe croup: Well-established benefits with consistent evidence 1, 4
• Single dose is sufficient for most cases 7, 1, 5

Additional Management

After administering dexamethasone:

• Antipyretics for comfort: Acetaminophen 10-15 mg/kg every 4-6 hours (maximum 5 doses/24 hours) for fever-related discomfort 8, 2
• Adequate hydration: Encourage regular fluid intake 8
• Avoid aspirin in children under 16 years due to Reye's syndrome risk 3, 8

When to Consider Nebulized Epinephrine

Reserve for moderate to severe croup only 1:

• Significant respiratory distress despite dexamethasone
• Stridor at rest
• Dose: 0.5 mL of 2.25% racemic epinephrine diluted in 2.5 mL saline 7
• If two epinephrine treatments are needed, hospitalize the child 7

Follow-Up Instructions

Return immediately or call 911 if 3, 2:

• Respiratory distress worsens (increased work of breathing, retractions, grunting)
• Cyanosis develops
• Child becomes drowsy or difficult to arouse
• Unable to maintain hydration
• Symptoms worsen despite treatment

Routine follow-up: Re-evaluate if not improving within 48 hours 2

Common Pitfalls to Avoid

• Do not withhold dexamethasone due to fever or tachycardia - these are expected findings in croup and not contraindications 1
• Do not use humidification therapy - not proven beneficial 1
• Do not prescribe antibiotics - croup is viral (most commonly parainfluenza virus) 7, 1
• Do not use antihistamines or decongestants - no proven effect on viral croup 7
• Do not delay treatment waiting for "severe" symptoms - all children with croup benefit from dexamethasone 1, 4