How should I manage the airway and breathing of a 6‑month‑to‑3‑year‑old child with croup who has audible stridor at rest, a barking cough, and mild‑to‑moderate respiratory distress?

Respiratory Management of Croup in Young Children

Immediate Airway Assessment and Positioning

For a child aged 6 months to 3 years with croup presenting with stridor at rest and mild-to-moderate respiratory distress, immediately administer oral dexamethasone 0.15-0.6 mg/kg (maximum 10-12 mg) as a single dose, and add nebulized epinephrine 0.5 ml/kg of 1:1000 solution (maximum 5 ml) for any child with stridor at rest. 1, 2

Airway Positioning

• Position children under 2 years in a neutral head position with a roll under the shoulders to optimize airway patency, as excessive neck flexion or extension can worsen obstruction in this age group 1
• Assess for signs of respiratory distress including stridor, accessory muscle use, tracheal tug, sternal/subcostal/intercostal recession, and agitation (which may indicate hypoxemia) 3, 1

Oxygen Therapy Protocol

• Administer supplemental oxygen to maintain SpO2 ≥94% using nasal cannulae, head box, or face mask 1, 2
• Apply oxygen to the child's face even if stridor suggests upper airway obstruction, as hypoxemia can develop rapidly 3
• Agitation may indicate hypoxia rather than anxiety—do not withhold oxygen from an agitated child 1

Medication Administration

First-Line Treatment

• Oral dexamethasone 0.15-0.6 mg/kg (maximum 10-12 mg) as a single dose is the cornerstone of treatment for all severities of croup 1, 2, 4
• If oral administration is not feasible due to vomiting or severe distress, use nebulized budesonide 2 mg as an equally effective alternative 2

Nebulized Epinephrine for Moderate-Severe Cases

• Administer nebulized epinephrine 0.5 ml/kg of 1:1000 solution (maximum 5 ml) for any child with stridor at rest or respiratory distress 1, 2
• The effect is short-lived, lasting only 1-2 hours, requiring close monitoring 1, 2
• Never discharge a patient within 2 hours of nebulized epinephrine due to risk of rebound airway obstruction 1, 5

Observation and Monitoring Protocol

Post-Epinephrine Observation

• Observe for at least 2 hours after each dose of nebulized epinephrine to assess for rebound symptoms 1, 2, 5
• If a second dose is required, restart the 2-hour observation clock 1
• Monitor oxygen saturation at least every 4 hours for patients on oxygen therapy 1

Multiple Dose Considerations

• Consider hospital admission after 3 total doses of nebulized epinephrine rather than the traditional 2 doses, which reduces unnecessary hospitalizations by 37% without increasing adverse outcomes 1, 2
• This "3 is the new 2" approach is supported by recent American Academy of Pediatrics guidelines 1, 2

Hospitalization Criteria

Admit to hospital if any of the following are present:

• Need for ≥3 doses of nebulized epinephrine 1, 2
• Oxygen saturation <92% 1, 2
• Age <18 months with severe symptoms 1, 2
• Respiratory rate >70 breaths/min 1, 2
• Persistent difficulty breathing despite treatment 1, 2

Critical Pitfalls to Avoid

Medication Errors

• Never give over-the-counter cough or cold medications, antihistamines, or decongestants—they provide no benefit and may cause harm, including documented fatalities in young children 1, 6
• Never use codeine-containing medications due to risk of respiratory depression 2
• Do not give antibiotics as croup is viral in etiology 2

Management Errors

• Never use nebulized epinephrine in outpatient settings where immediate return is not feasible, as rebound symptoms can be life-threatening 1, 2
• Do not rely on humidified or cold air therapy as evidence does not support benefit 1, 2
• Avoid excessive handling of the child, as this increases metabolic and oxygen requirements 1, 2

Discharge Criteria and Follow-Up

Discharge is appropriate when:

• Resolution of stridor at rest 2
• Minimal or no respiratory distress 2
• Adequate oral intake 2
• Reliable family able to monitor and return if worsening 1

Discharge Instructions

• Instruct parents to return immediately for extreme fatigue, lethargy, difficulty staying awake, worsening stridor, or increased work of breathing 2
• Schedule follow-up with primary care provider if not improving after 48 hours 1, 2
• Reassure parents that the barking cough sounds frightening but the airway remains open in most cases, and croup resolves completely without long-term effects 2

Alternative Diagnoses to Consider

If the child fails to respond to standard treatment or presents atypically, consider:

• Bacterial tracheitis (high fever, toxic appearance, purulent secretions) 1
• Foreign body aspiration (sudden onset without prodrome, unilateral findings) 1
• Epiglottitis (drooling, tripod positioning, toxic appearance) 7
• Retropharyngeal abscess (neck stiffness, dysphagia) 1

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