What is the recommended evaluation and treatment for a child aged 6 months to 5 years who presents with a barking cough?

Barking Cough in Children: Evaluation and Management

A barking cough in a child aged 6 months to 5 years is croup until proven otherwise, and treatment should begin immediately with oral dexamethasone 0.15-0.60 mg/kg (maximum 10 mg) regardless of severity. 1

Immediate Clinical Assessment

Evaluate the following specific features to determine severity:

• Stridor at rest (indicates moderate-to-severe disease requiring nebulized epinephrine) 1
• Use of accessory muscles, tracheal tug, or chest wall retractions 1
• Respiratory rate (>70 breaths/min in infants or >50 breaths/min in older children warrants admission consideration) 1
• Oxygen saturation (<92% requires supplemental oxygen and admission) 1
• Agitation (may signal hypoxemia rather than anxiety) 1

The diagnosis is clinical—radiographic studies are unnecessary and should be avoided unless you suspect an alternative diagnosis such as foreign body aspiration, bacterial tracheitis, or retropharyngeal abscess. 1

Treatment Algorithm

All Cases (Mild to Severe)

Administer oral dexamethasone 0.15-0.60 mg/kg (maximum 10 mg) as a single dose immediately. This reduces symptom severity, emergency department revisits, and hospital admissions. 1, 2, 3 If the child cannot tolerate oral medication, use intramuscular dexamethasone at the same dose. 3

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

Add nebulized epinephrine 0.5 mL/kg of 1:1000 solution (racemic epinephrine). 1, 4 The effect is rapid but short-lived, lasting only 1-2 hours. 1

Critical: Observe the child for at least 2 hours after the last epinephrine dose to monitor for rebound symptoms. 1, 4 Never discharge a patient within this window, and never use nebulized epinephrine in outpatient settings where immediate return is not feasible. 1

Supportive Care

• Administer supplemental oxygen to maintain SpO₂ ≥94% using nasal cannula, head box, or face mask. 1
• Minimize handling of severely ill children to reduce metabolic demand. 1
• Avoid chest physiotherapy—it provides no benefit and may cause harm. 1

Hospitalization Criteria

Admit the child if:

• Three or more doses of nebulized epinephrine are required 1
• Oxygen saturation <92% on room air 1
• Age <18 months with severe symptoms 1
• Persistent respiratory distress or stridor at rest after treatment 1
• Family unable to provide appropriate observation at home 1

Discharge Criteria

The child may be discharged when all of the following are met:

• 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 1
• Respiratory rate <50 breaths/min 1
• Reliable caregiver able to monitor and return if needed 1

Important Differential Diagnoses to Exclude

While croup is the most common cause of barking cough in this age group, consider:

• Bacterial tracheitis (toxic appearance, high fever, rapid deterioration) 1, 2
• Foreign body aspiration (sudden onset without prodrome, unilateral findings) 1, 2
• Epiglottitis (rare post-Hib vaccine, but presents with drooling, tripod positioning, toxic appearance) 2
• Retropharyngeal or peritonsillar abscess (dysphagia, neck stiffness, asymmetric findings) 2

Common Pitfalls to Avoid

• Never perform blind finger sweeps in suspected foreign body aspiration—this may push the object deeper. 1
• Do not give over-the-counter cough or cold medications—they provide no benefit and may cause harm, especially in children under 2 years. 1, 5
• Do not rely on lateral neck radiographs for diagnosis—clinical assessment is superior and radiographs are often unnecessary. 1
• Do not use antihistamines or decongestants—they are ineffective for croup and carry potential adverse effects. 1

Follow-Up Instructions

Instruct families to:

• Return immediately if respiratory distress worsens, stridor increases, or the child cannot maintain hydration 1
• Follow up with primary care if symptoms have not improved within 48 hours 1
• Use antipyretics for fever control to improve comfort 1
• Maintain adequate fluid intake 1

When Cough Persists Beyond 4 Weeks

If the barking cough persists beyond 4 weeks, it transitions to chronic cough and requires systematic evaluation including chest radiograph and assessment for underlying airway abnormalities such as tracheomalacia or asthma. 1 At this point, follow pediatric chronic cough guidelines rather than treating as acute croup. 6