5 year vaccinated male with two day history of URI symptoms presenting with bark-like cough that began in the middle of the night.  According to mother, he was initially distressed but is back to baseline now.  ROS otherwise negative.  Afebrile and normal vital signs.  Exam remarkable for the presence of a bark-like cough consistent with croup and the absence of inspriatory stridor.  He was treated with 10 mg po Decadron and discharged.

Teaching Points:

1. Parainfluenza virus most common cause
2. Mild: characteristic cough present without stridor
3. Moderate: cough and stridor present with agitation
4. Severe: stridor at rest
5. All should receive 0.6 mg/kg po Decadron.  However, one study demonstrates that smaller doses achieve the same outcomes.  (Chub-Uppakarn S, Sangsupawanich P.  A Randomized Comparison of Dexamethasone 0.15 mg/kg vs 0.6mg/kg for the treatment of moderate to severe croup.  International Journal of Pediatric Otorhinolaryngology (2007) 71, 473—477)

6. Stridor at rest should receive racemic epi.  If given, patients should be monitored for 2 hours and then discharged. If not better, give a second dose and admit the patient (or transfer to pediatric center).
7. Counsel parents about symptom control at home to prevent recidivism.  Avoid cough suppressants.  Home remedies that been shown to work include turning on shower water, taking patient outside in colder weather (properly clothed), and honey in patients greater than 1 year.