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Difficulty: EasyPediatric Respiratory Disorders

A 24-month-old toddler is evaluated in an outpatient clinic during the late fall due to a distinctive, harsh cough. Her mother reports that the child had a runny nose and a temperature of 37.6°C (99.7°F) for the past two days. Last night, the child woke up with a hoarse cry and a cough that the mother describes as sounding like a "seal barking." During the current examination, the patient is playful and sitting comfortably on her mother's lap. Vital signs reveal a heart rate of 112/min, a respiratory rate of 24/min, and an oxygen saturation of 99% on room air. There is no visible chest wall retraction, and no abnormal airway sounds are heard while the child is resting quietly. Auscultation of the lung fields reveals clear breath sounds bilaterally. Which of the following is the most appropriate next step in the management of this patient?

  1. Oral administration of a single dose of dexamethasoneAnswer
  2. B
    Inhalation of a short-acting beta-2 agonist
  3. C
    Initiation of an oral penicillin-class antibiotic
  4. D
    Delivery of aerosolized racemic epinephrine
  5. E
    Observation with supportive care and nasal bulb suctioning alone

Answer

Oral administration of a single dose of dexamethasone
The patient's presentation of a barking cough, hoarse voice, and preceding upper respiratory symptoms is highly characteristic of croup (laryngotracheobronchitis), which is most commonly caused by the parainfluenza virus. The absence of stridor at rest and the lack of respiratory distress indicate that this is a mild case. The cornerstone of management for all severities of croup is the administration of corticosteroids. A single dose of oral dexamethasone is highly effective at decreasing laryngeal edema, thereby reducing the duration of symptoms, the rate of return visits, and the need for hospital admission.

Step-by-Step Solution

1
Identify the clinical syndrome based on the presentation.
The patient has a barking cough, hoarseness, and preceding viral symptoms, which are classic for croup (laryngotracheobronchitis).
Recognizing the hallmark signs of upper airway edema helps establish the correct diagnosis.
2
Assess the severity of the condition.
The patient has no stridor at rest, no chest wall retractions, and normal oxygen saturation, classifying this as mild croup.
Severity classification dictates the appropriate therapeutic interventions.
3
Determine the standard pharmacological management for this severity level.
All patients with croup, including mild cases, benefit from a single dose of corticosteroids (e.g., dexamethasone).
Corticosteroids reduce airway inflammation, shorten the course of the illness, and decrease the need for future medical interventions.

Key Concept

The hallmark of mild croup is a barking cough without stridor at rest, and the standard of care includes a single dose of a corticosteroid, typically dexamethasone, to reduce airway inflammation.
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Topics

Pediatric Respiratory Disorders

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