What is the appropriate evaluation and management for a 12‑year‑old child presenting with a bark‑like cough?

Barky Cough in a 12-Year-Old: Evaluation and Management

A barky cough in a 12-year-old most commonly indicates viral croup (laryngotracheobronchitis), and you should treat with a single dose of oral dexamethasone 0.6 mg/kg (maximum 10 mg) regardless of severity. 1

Immediate Clinical Assessment

Evaluate the following to determine severity and guide management:

• Stridor pattern: Stridor at rest indicates moderate-to-severe disease requiring immediate intervention, while stridor only with agitation suggests mild disease 2, 3
• Work of breathing: Look for suprasternal/intercostal retractions, nasal flaring, or use of accessory muscles 4
• Mental status: Agitation or lethargy signals impending respiratory failure 4
• Oxygen saturation: <92% requires supplemental oxygen and hospitalization 5
• Fever pattern: Low-grade fever is typical for viral croup; high fever (>39°C) raises concern for bacterial tracheitis or epiglottitis 2, 6

Differential Diagnosis to Exclude

The barky cough quality strongly suggests croup, but you must actively exclude:

• Epiglottitis: Presents with drooling, inability to swallow, toxic appearance, and preference for sitting upright—this is a medical emergency 2, 4
• Foreign body aspiration: Sudden onset without prodromal upper respiratory symptoms, unilateral findings on exam 4
• Bacterial tracheitis: High fever, toxic appearance, purulent secretions, and rapid deterioration 6

Do not obtain lateral neck radiographs or perform laryngoscopy unless you suspect one of these alternative diagnoses—croup is a clinical diagnosis and imaging delays treatment. 6

Evidence-Based Treatment Protocol

All Patients (Mild to Severe)

Administer oral dexamethasone 0.6 mg/kg (maximum 10 mg) immediately. 3, 7, 6

• This single dose reduces symptom severity, return visits, emergency department visits, and hospitalizations across all severity levels 3, 7
• Onset of action is approximately 6 hours 2
• If the patient cannot tolerate oral medication, use intramuscular dexamethasone 0.6 mg/kg or nebulized budesonide as alternatives 3
• Lower doses (0.15 mg/kg) may be equally effective, but 0.6 mg/kg remains the standard based on the strongest evidence 7

Moderate to Severe Croup (Stridor at Rest)

Add nebulized racemic epinephrine 0.5 mL of 2.25% solution in 3 mL normal saline (or L-epinephrine 5 mL of 1:1000 if racemic unavailable). 2, 3, 6

• Provides rapid symptom relief within minutes, bridging the gap until dexamethasone takes effect 2, 3
• Critical caveat: Observe for at least 2–3 hours after administration because rebound airway obstruction can occur 2, 7
• Patients who remain stable after this observation period can be safely discharged home 7
• Simultaneous administration of corticosteroids and epinephrine reduces intubation rates in severe croup 3

Supportive Care

• Maintain calm environment: Agitation worsens airway obstruction 4
• Ensure adequate hydration: Helps thin secretions 5
• Humidified air: Maintain at least 50% relative humidity, though evidence for benefit is limited 2, 7
• Supplemental oxygen: Only if oxygen saturation <92% 5

Disposition Criteria

Hospitalize if:

• Stridor at rest persists after treatment 4
• Respiratory distress (retractions, tachypnea >50 breaths/min) 5
• Oxygen saturation <92% 5
• Signs of exhaustion or altered mental status 4
• Inability to maintain oral hydration 5

Safe for discharge if:

• No stridor at rest 2–3 hours after epinephrine (if given) 7
• Normal oxygen saturation on room air 5
• Adequate oral intake 5
• Reliable caregiver with clear return precautions 5

When Cough Persists Beyond Expected Timeline

If the barky cough continues beyond 1–2 weeks or becomes chronic (≥4 weeks), this is no longer typical viral croup:

• At 4 weeks: Obtain chest radiograph and spirometry (with pre/post-bronchodilator testing) to evaluate for chronic cough etiologies 1
• Consider alternative diagnoses: Tracheomalacia (causes persistent barky cough), habit cough, or underlying airway abnormality 1
• Do not empirically treat for asthma unless other features of asthma are present (recurrent wheeze, exercise intolerance, nocturnal symptoms) 1, 8

Common Pitfalls to Avoid

• Do not withhold steroids in mild croup: Even mild cases benefit from dexamethasone, with reduced progression and return visits 3, 7
• Do not discharge immediately after epinephrine: The 2–3 hour observation period is mandatory to detect rebound obstruction 2, 7
• Do not use over-the-counter cough medications: These have no proven efficacy and potential for harm in children 5
• Do not obtain routine radiographs: Imaging is only indicated when the diagnosis is uncertain or alternative pathology is suspected 6