From the Guidelines
Croup treatment should prioritize reducing airway inflammation and supporting breathing, with a focus on early initiation of systemic steroids, such as oral dexamethasone, to decrease hospital admissions and improve symptoms. For mild cases, cool mist therapy and keeping the child calm are often sufficient 1. Moderate to severe croup typically requires a single dose of oral dexamethasone (0.6 mg/kg, maximum 16 mg), which reduces inflammation and improves symptoms within hours.
Key Interventions
- Early initiation of systemic steroids
- Up to a 2 hour ED observation time after each racemic epinephrine (RE) dose
- Consideration for admission after 3 total doses of RE
- Avoiding imaging but recommending further workup if a patient fails to respond to RE For severe respiratory distress, nebulized epinephrine (racemic epinephrine 2.25% solution, 0.5 mL in 2.5 mL saline, or L-epinephrine 1:1000,5 mL) provides temporary relief while steroids take effect 1. Children receiving epinephrine should be observed for at least 2-3 hours as symptoms may return.
Management and Hospitalization
- Most children can be managed at home after treatment
- Those with persistent stridor at rest, respiratory distress, or inability to drink require hospitalization
- Antibiotics are not effective since croup is typically viral
- Humidified air or taking the child into a steamy bathroom may provide comfort, though evidence for this is limited Croup symptoms often worsen at night and typically resolve within 3-5 days, with steroids shortening this duration by reducing inflammation of the subglottic tissues where the viral infection causes narrowing of the airway 1.
From the Research
Croup Treatment Overview
- Croup is a common childhood disease characterized by sudden onset of a distinctive barking cough, stridor, hoarse voice, and respiratory distress resulting from upper airway obstruction 2.
- The introduction of steroids in the treatment of croup has seen a significant reduction in hospital admissions and improved outcomes for children 2.
Treatment Strategies
- In mild to moderate croup, giving prednisolone 1.0 mg/kg and reviewing in 1 hour is a recommended treatment strategy 2.
- In severe or life-threatening croup, giving 4 mL of adrenaline 1:1000 (undiluted) via nebuliser and sending immediately to hospital via ambulance is a recommended treatment strategy 2.
- A single dose of oral, intramuscular, or intravenous dexamethasone improves symptoms and reduces return visits and length of hospitalization in children with croup of any severity 3.
- In patients with moderate to severe croup, the addition of nebulized epinephrine improves symptoms and reduces length of hospitalization 3.
Effectiveness of Treatments
- Corticosteroids, such as dexamethasone, are effective in treating croup and reducing the need for hospitalization 3, 4.
- Nebulized epinephrine is effective in reducing the severity of symptoms in moderate to severe croup 3, 5.
- Heliox inhalation may have a short-term benefit in children with moderate to severe croup who have been administered oral or intramuscular dexamethasone, but its role remains uncertain 6, 5.
- Humidified air provides no demonstrable benefit in the acute setting 5.
Key Considerations
- Assessment of airway, breathing, and circulation, focusing on airway, is paramount in treating croup 2.
- It is essential to take care not to cause the child undue distress during treatment 2.
- Laboratory studies are seldom needed for diagnosis of croup, and viral cultures and rapid antigen testing have minimal impact on management 3.