A 3-year-old with stridor and an incomplete immunization record

The illness began as a coryzal prodrome with low fever, then developed a barking cough, hoarse voice, and inspiratory stridor that is worse at night. That sequence is typical of viral laryngotracheitis, croup, most often parainfluenza. Epiglottitis is suggested by high fever, drooling, muffled voice, toxic appearance, and a preference for sitting still without coughing; this child has none of those, and the presence of a barking cough argues strongly against it. Bacterial tracheitis can follow croup and is suggested by high fever, purulent secretions, and rapid deterioration, which is not yet the picture. Foreign-body aspiration gives sudden onset without a febrile prodrome. The severity grading is moderate to severe croup because there is stridor at rest plus suprasternal retraction; mild croup has stridor only with agitation. The immunization history is a separate thread: an incomplete record raises the question of Haemophilus influenzae type b and diphtheria coverage, but it does not change the immediate management, and the child should not be assumed unimmunized or immunized. The absence of drooling and toxicity means the airway should not be instrumented for inspection in the emergency department.

Give nebulized adrenaline for stridor at rest, which buys time by reducing mucosal oedema, and give a single dose of systemic dexamethasone, which reduces the need for repeat adrenaline and shortens the illness. Provide humidified oxygen if saturation falls, keep the child calm and upright in the parent's lap, and avoid unnecessary throat examination, IV cannulation, and separation from the parent, all of which can precipitate airway obstruction. Observe for at least 3 to 4 hours after adrenaline, because rebound can occur. Disposition: this child has stridor at rest and retraction, so she is not a candidate for home discharge after a single dose. The absence of an intensive care bed does not justify sending her home; it requires escalation. Contact the receiving paediatric centre, describe the severity and the trend, and arrange transfer with a clinician escort and airway equipment, or arrange a monitored bed in the department with continuous observation and a clear escalation plan if stridor worsens. Document the capacity problem and the escalation in the record.

A missing card is not evidence of vaccination, and it is also not evidence against it. The correct approach is to search the national immunization register or the polyclinic record, ask the mother which vaccines she recalls and where they were given, and record the uncertainty explicitly. Current illness with moderate croup is not a reason to withhold routine vaccines that are due, but vaccination should not be given during an acute moderate-to-severe illness with fever; it should be deferred until recovery and then completed according to the national schedule, with catch-up doses for anything missed. If the child is found to be unimmunized or under-immunized, that is a public-health finding requiring counselling of the family and a written catch-up plan, not a punitive response. Do not give immunoglobulin or antivirals for croup; they have no role. The key reasoning is to separate the acute airway problem, which is treated now, from the preventive problem, which is solved by verification and a documented catch-up schedule rather than by guesswork.