General Pediatrics

Q) A 2-month-old male infant is brought to the clinic with a history of noisy breathing since birth, which is described as high-pitched and expiratory. The noise worsens when the baby is crying, feeding, or in the supine position. There is no history of cyanosis or apneic episodes. Growth parameters are within normal limits. On examination, there is an expiratory stridor. Chest X-ray is normal. Flexible bronchoscopy shows dynamic collapse of the intrathoracic trachea during expiration.

What is the most likely diagnosis?

A. Laryngomalacia
B. Tracheomalacia
C. Subglottic stenosis
D. Bronchiolitis
E. Foreign body aspiration

B. Tracheomalacia

  • Tracheomalacia in infants is usually congenital, caused by underdevelopment of tracheal cartilage.

  • Presents with expiratory stridor, unlike laryngomalacia which causes inspiratory stridor.

  • Symptoms worsen with crying, feeding, and supine positioning, due to increased intrathoracic pressure during expiration.

  • Flexible bronchoscopy is the gold standard for diagnosis, revealing >50% collapse of the tracheal lumen during expiration.

  • Most cases are mild and improve spontaneously by age 12–24 months as cartilage stiffens.


A 3-year-old boy is brought to the emergency department at night with sudden onset of a barking cough, hoarseness, and stridor. The parents report that he had a mild fever and rhinorrhea for two days. On examination, he is alert, has a barking cough, inspiratory stridor, and mild subcostal retractions, but is maintaining oxygen saturation above 94% on room air. A soft tissue neck X-ray was performed, showing the "steeple sign".

Which of the following is the most appropriate initial management?

A. Intramuscular dexamethasone and nebulized epinephrine
B. Oral azithromycin and salbutamol nebulization
C. Humidified oxygen and nebulized hypertonic saline
D. Immediate intubation and IV corticosteroids
E. Oral dexamethasone and supportive care

Correct Answer: E. Oral dexamethasone and supportive care

  • Croup is typically caused by parainfluenza virus and affects children aged 6 months to 5 years.

  • Classic features: barking cough, inspiratory stridor, hoarseness, low-grade fever, and worse at night.

  • The "steeple sign" on neck X-ray represents subglottic narrowing but is not always necessary for diagnosis, which is primarily clinical.

  • Mild croup (no or minimal stridor at rest, no hypoxia, no severe distress): managed with oral dexamethasone (0.15–0.6 mg/kg) and supportive care.

  • Nebulized epinephrine is reserved for moderate to severe croup with significant stridor at rest and respiratory distress.

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