What is the diagnosis and recommended management for a child presenting with a barking cough (croup), including severity assessment and treatment options?

Hacking Barking Cough in Children: Diagnosis and Management

A child presenting with a barking cough most likely has viral croup, which should be treated with a single dose of oral dexamethasone (0.15-0.60 mg/kg, maximum 10 mg) regardless of severity, with nebulized epinephrine reserved for moderate to severe cases showing stridor at rest or respiratory distress. 1, 2, 3

Immediate Clinical Assessment

The diagnosis of croup is made clinically based on the characteristic presentation of:

• Barking or "seal-like" cough that is the hallmark feature 4, 5, 6
• Inspiratory stridor (may be present at rest in moderate-severe cases) 1, 5, 3
• Hoarseness due to laryngeal inflammation 7
• Preceding upper respiratory infection with low-grade fever and coryza 6, 2, 3
• Variable respiratory distress with accessory muscle use, retractions, or nasal flaring 1, 5

Key severity indicators to assess immediately include: ability to speak/cry normally, respiratory rate, heart rate, presence of stridor at rest, use of accessory muscles, and oxygen saturation 1. Life-threatening signs such as silent chest, cyanosis, fatigue/exhaustion, or poor respiratory effort indicate severe disease requiring immediate intervention 1.

Critical Differential Diagnoses to Exclude

Before confirming croup, you must actively exclude:

• Bacterial tracheitis (toxic appearance, high fever, rapid deterioration) 1, 2
• Epiglottitis (drooling, tripod positioning, toxic appearance) 5, 2, 3
• Foreign body aspiration (sudden onset without prodrome, unilateral findings) 1, 5, 2
• Retropharyngeal or peritonsillar abscess (severe dysphagia, neck stiffness, asymmetric findings) 1, 2, 3

Important caveat: The presence of a barking cough does NOT exclude other serious diagnoses—a barking cough can also occur with tracheomalacia or even habit/tic cough in chronic cases 4. However, in the acute setting with typical viral prodrome, croup is by far the most likely diagnosis 2, 3.

Diagnostic Testing: What NOT to Do

Radiographic studies are generally unnecessary and should be avoided unless there is concern for an alternative diagnosis 1. Laboratory studies including viral cultures and rapid antigen testing have minimal impact on management and are not routinely recommended 3. Lateral neck radiographs should not be relied upon for diagnosis, as clinical assessment is more important 1.

Treatment Algorithm

All Severity Levels (Mild, Moderate, Severe)

Administer oral dexamethasone 0.15-0.60 mg/kg (maximum 10 mg) as a single dose immediately 1, 2, 3. This recommendation applies to ALL children with croup, including those with mild disease 1, 2. The evidence shows that early corticosteroid intervention reduces symptom severity, return visits, emergency department visits, and hospital admissions 2, 3, 7.

If the child cannot tolerate oral medication, use intramuscular dexamethasone at the same dose 6, 3, 7. The onset of action is approximately 6 hours after administration 6.

Moderate to Severe Croup (Stridor at Rest or Respiratory Distress)

Add nebulized epinephrine 0.5 mL/kg of 1:1000 solution (racemic epinephrine) to the dexamethasone 1, 6, 2, 3. This provides rapid but temporary relief lasting only 1-2 hours 1, 6.

Critical monitoring requirement: The child MUST be observed for at least 2 hours after each dose of nebulized epinephrine to assess for rebound symptoms 1, 6, 2. If a second dose is required, restart the 2-hour observation clock 1.

Oxygen Therapy

Administer oxygen to maintain saturation ≥94% using simple oxygen masks or non-rebreathing masks as needed 1. Hypoxemia (oxygen saturation <92-93%) is an indicator for hospital admission 1, 8.

Supportive Care

• Maintain adequate hydration through continued breastfeeding or formula/fluid intake 9
• Minimize handling to reduce metabolic and oxygen requirements 8
• Keep the child comfortable with antipyretics if febrile 8
• Position appropriately: For children under 2 years, use a neutral head position with a roll under the shoulders to optimize airway patency 1

What NOT to Do: Common Pitfalls

Do NOT give over-the-counter cough or cold medications to children with croup—they provide no therapeutic benefit and may cause harm 1. Between 1969-2006, there were 54 fatalities associated with decongestants and 69 fatalities associated with antihistamines in young children 8.

Do NOT give antihistamines or decongestants—they are ineffective for croup and carry potential adverse effects 1.

Do NOT use humidification therapy—it has not been proven beneficial despite historical use 2, 3.

Do NOT perform blind finger sweeps if foreign body aspiration is suspected, as this may push objects further into the pharynx 1.

Do NOT discharge a patient within 2 hours of nebulized epinephrine administration due to the risk of rebound symptoms 1.

Hospitalization Criteria

Consider hospital admission if:

• Three or more doses of racemic epinephrine are required 1, 6
• Oxygen saturation <92% 1, 8
• Age <18 months with severe symptoms 1, 8
• Respiratory rate >70 breaths/min (infants) 8
• Persistent stridor at rest despite treatment 5
• Signs of exhaustion, toxicity, or respiratory distress 5
• Inability of family to provide appropriate observation 1

Recent evidence shows that limiting hospital admission until 3 doses of racemic epinephrine are needed can reduce hospitalization rates by 37% without increasing revisits or readmissions 1.

Discharge Criteria and Follow-Up

Discharge is appropriate when:

• No stridor at rest
• Normal oxygen saturation on room air
• Adequate oral intake
• Reliable family able to monitor and return if worsening 1

Provide clear instructions to return immediately if:

• Respiratory distress develops 9
• Stridor worsens or returns 1
• Inability to feed or signs of dehydration develop 9
• Cyanosis or altered mental status occurs 1

Expected clinical course: Most children with croup improve within 48 hours, with resolution of cough within 2 days in the majority of cases 2. If symptoms are deteriorating or not improving after 48 hours, the child should be reviewed by a healthcare provider 8.

Special Considerations

For recurrent episodes of croup: Consider asthma as a differential diagnosis, especially if cough worsens at night, episodes are triggered by exercise or irritants, or there is a family history of asthma or atopy 1. Evaluation for underlying airway abnormalities such as laryngomalacia or tracheomalacia should be considered after the acute episode resolves 1.

Etiology: Croup is most commonly caused by parainfluenza viruses (types 1-3), but identifying the specific pathogen does not alter treatment 1, 6, 2, 7.