What is the appropriate evaluation and management for a 6‑month‑to‑3‑year‑old child presenting with barking cough, hoarse voice, and inspiratory stridor suggestive of croup?

Evaluation and Management of Croup in Young Children

Clinical Diagnosis

Croup is diagnosed clinically in children 6 months to 3 years presenting with the characteristic triad of barking ("seal-like") cough, hoarse voice, and inspiratory stridor, typically preceded by upper respiratory symptoms and low-grade fever. 1, 2, 3

Key Diagnostic Features to Assess:

• Barking cough is the hallmark symptom that distinguishes croup from other causes of stridor 1
• Inspiratory stridor indicates laryngeal/tracheal obstruction 2, 4
• Hoarseness from laryngeal inflammation 5, 3
• Severity indicators: ability to speak/cry normally, respiratory rate, heart rate, presence of stridor at rest, use of accessory muscles (retractions, tracheal tug, chest wall recession), and oxygen saturation 1
• Life-threatening signs: silent chest, cyanosis, fatigue/exhaustion, poor respiratory effort, or agitation (which may signal hypoxemia rather than anxiety) 1

Diagnostic Testing:

• Radiographic studies are unnecessary and should be avoided unless alternative diagnoses are suspected 1, 3
• Viral cultures and rapid antigen testing have minimal impact on management and are not recommended 3
• Lateral neck radiographs should not be relied upon, as clinical assessment is superior 1

Critical Differential Diagnoses to Exclude:

• Bacterial tracheitis 1
• Epiglottitis 3
• Foreign body aspiration (never perform blind finger sweeps, as this may push objects deeper) 1
• Retropharyngeal or peritonsillar abscess 1

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Immediate Treatment Algorithm

All Severity Levels:

Administer oral dexamethasone 0.15–0.60 mg/kg (maximum 10 mg) as a single dose immediately to all children with croup, regardless of severity. 1, 4, 3, 6 This is the mainstay of treatment and reduces symptom severity, return visits, and hospitalization rates. 4, 3

• Alternative if oral route not tolerated: Nebulized budesonide 2 mg or intramuscular dexamethasone 0.6 mg/kg 4, 6
• Onset of action: Approximately 6 hours, so immediate symptom relief requires additional interventions in moderate-to-severe cases 2

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

Add nebulized epinephrine 0.5 mL/kg of 1:1000 solution (racemic epinephrine) to oral dexamethasone for rapid but temporary relief. 1, 4, 3

• Duration of effect: Only 1–2 hours 1
• Critical safety requirement: Observe the patient for at least 2 hours after the last epinephrine dose to monitor for rebound symptoms 1, 2
• Never discharge within 2 hours of nebulized epinephrine administration 1
• Never use in outpatient settings where immediate return is not feasible 1

Supportive Care:

• Oxygen therapy: Administer supplemental oxygen via nasal cannula, head box, or face mask to maintain SpO₂ ≥94% 1
• Positioning: Use neutral head position with a roll under the shoulders in children <2 years to optimize airway patency 1
• Minimize handling to reduce metabolic demand and oxygen consumption in severely ill children 1
• Antipyretics for fever control to improve comfort 1

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Hospitalization Criteria

Admit to the hospital when any of the following are present: 1

• Three or more doses of nebulized epinephrine are required (this criterion alone reduces unnecessary admissions by 37% without increasing revisits) 1
• Age <18 months with severe symptoms 1
• Oxygen saturation <92% on room air 1
• Respiratory rate >70 breaths/min 1
• Inability of family to provide appropriate observation at home 1

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Discharge Criteria

Children may be discharged home when ALL of the following are met: 1

• At least 2 hours have elapsed since the last nebulized epinephrine dose with no rebound symptoms 1
• Oxygen saturation >92% on room air 1
• No signs of respiratory distress (no stridor at rest, no accessory muscle use) 1
• Respiratory rate <50 breaths/min (or <40 breaths/min in older children) 1
• Reliable caregiver able to monitor the child and seek care if needed 1

Discharge Instructions:

• Return immediately if respiratory distress worsens, stridor increases, or the child cannot maintain adequate hydration 1
• Follow up with primary care if symptoms have not improved within 48 hours 1
• Maintain adequate fluid intake to prevent dehydration 1

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Interventions to Avoid

• Do NOT give over-the-counter cough or cold medications to children with croup, as they provide no therapeutic benefit and may cause harm 1, 7
• Do NOT give antihistamines or decongestants, as they are ineffective and carry potential adverse effects 1, 7
• Do NOT use honey for croup (honey is only helpful for post-viral cough, not the inflammatory airway obstruction of croup) 1
• Do NOT rely on humidified or cold air, as current evidence does not show benefits 1
• Do NOT perform chest physiotherapy, as it offers no clinical benefit and may cause harm 1

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Special Considerations

Recurrent Croup:

Two or more episodes per year warrant evaluation for underlying structural or inflammatory airway abnormalities. 5

• Consider asthma if cough worsens at night, episodes are triggered by exercise/irritants, or there is family history of asthma/atopy 1
• Consider flexible bronchoscopy in cases of severe, persistent, or atypical symptoms, as up to 68% of infants with stridor have concomitant lower airway abnormalities 1
• Consider anatomical abnormalities such as laryngomalacia or tracheomalacia 1

Observation After Multiple Epinephrine Doses:

• Restart the 2-hour observation clock after each dose of nebulized epinephrine 1
• If a second dose is required, continue monitoring for at least 2 hours after the second dose 1
• After three total doses, strongly consider hospital admission rather than extended observation 1

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Common Pitfalls to Avoid

• Discharging too soon after epinephrine: Always observe for at least 2 hours to detect rebound symptoms 1, 2
• Mistaking agitation for anxiety: Agitation may signal hypoxemia and requires oxygen therapy 1
• Using adult cough management approaches: Children require pediatric-specific protocols 7
• Failing to consider alternative diagnoses: Bacterial tracheitis, foreign body aspiration, and epiglottitis can mimic croup 1, 3
• Performing blind finger sweeps: This can push foreign bodies deeper into the airway 1