What is the recommended assessment and treatment for a 2‑year‑old child with a hoarse, barking cough suggestive of croup?

Management of Hoarse Barking Cough in a 2-Year-Old Child

Immediate Assessment

Administer oral dexamethasone 0.15–0.60 mg/kg (maximum 10 mg) immediately to all children with croup, regardless of severity. 1

Clinical Diagnosis

• A barking ("seal-like") cough is the hallmark of viral croup and allows bedside diagnosis without imaging in children 6 months to 6 years of age. 1, 2, 3
• Assess severity by evaluating stridor at rest, use of accessory muscles, respiratory rate, oxygen saturation, and the child's ability to cry or speak normally. 1
• Radiographic studies are unnecessary and should be avoided unless you suspect an alternative diagnosis such as foreign body aspiration, bacterial tracheitis, or epiglottitis. 1

Severity Stratification

• Mild croup: Stridor only with agitation, no retractions, normal oxygen saturation. 1, 4
• Moderate-to-severe croup: Stridor at rest, intercostal retractions, respiratory distress, or oxygen saturation <94%. 1, 5
• Life-threatening signs: Silent chest, cyanosis, fatigue/exhaustion, or poor respiratory effort require immediate intervention. 1

Treatment Algorithm

All Severity Levels

• Give oral dexamethasone 0.15–0.60 mg/kg (maximum 10 mg) as a single dose; this is the mainstay of treatment. 1, 5, 3
• If the child cannot tolerate oral medication, use intramuscular dexamethasone 0.6 mg/kg or nebulized budesonide 2 mg. 1, 2, 5
• Position the child in a neutral head position (for children under 2 years, use a roll under the shoulders) to optimize airway patency. 1

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

• Add nebulized epinephrine 0.5 mL/kg of 1:1000 solution (or 4 mL of 1:1000 undiluted for practical dosing). 1, 6, 4
• Epinephrine provides rapid but temporary relief lasting only 1–2 hours. 1, 6
• Monitor the child for at least 2 hours after the last epinephrine dose to assess for rebound symptoms before considering discharge. 1, 6
• Administer supplemental oxygen to maintain oxygen saturation ≥94% using nasal cannulae, head box, or face mask. 1

Hospitalization Criteria

• Admit when three or more doses of nebulized epinephrine are required; this criterion reduces unnecessary admissions by 37% without increasing revisits. 1
• Consider admission for children <18 months with severe symptoms, oxygen saturation <92%, respiratory rate >70 breaths/min, or inability of the family to provide appropriate observation. 1

Discharge Criteria

Discharge only 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 or use of accessory muscles. 1
• Respiratory rate <50 breaths/min (or <40 breaths/min in older children). 1
• A reliable caregiver able to monitor the child and return if symptoms worsen. 1

Critical Pitfalls to Avoid

• Never discharge within 2 hours of nebulized epinephrine administration due to the risk of rebound airway obstruction. 1, 6
• Never use nebulized epinephrine in outpatient settings where immediate return is not feasible. 1
• Do not give over-the-counter cough or cold medications to children with croup; they provide no therapeutic benefit and may cause harm, including 54 deaths from decongestants and 69 deaths from antihistamines in children under 6 years between 1969–2006. 1, 7, 8
• Avoid honey in acute croup; honey is only helpful for post-viral cough and does not address the inflammatory airway obstruction of croup. 1
• Do not perform blind finger sweeps if foreign body aspiration is suspected, as this may push objects further into the pharynx. 1
• Chest physiotherapy offers no benefit and should not be used. 1
• Cold air and humidified air have no proven efficacy for croup symptoms. 1

Supportive Care and Follow-Up

• Minimize handling of severely ill children to reduce metabolic demand and oxygen consumption. 1
• Use antipyretics for fever control to improve comfort. 1
• Ensure adequate hydration to prevent dehydration. 1
• Instruct families to return immediately if respiratory distress worsens, stridor increases, or the child cannot maintain adequate hydration. 1
• Advise follow-up with the primary care provider if symptoms have not improved within 48 hours. 1, 7

Differential Diagnosis Considerations

• Bacterial tracheitis, epiglottitis, foreign body aspiration, and retropharyngeal abscess must be considered in children who fail to respond to standard croup treatment or present with atypical features. 1, 3
• If symptoms persist beyond 4 weeks or are severe/atypical, consider flexible bronchoscopy, as up to 68% of infants with persistent stridor have concomitant lower airway abnormalities. 1