What are the management and exclusion guidelines for a child with croup?

From the Guidelines

School exclusion for a child with croup is not necessary once the child is fever-free for 24 hours and respiratory symptoms have significantly improved, as this approach prioritizes the child's quality of life and minimizes unnecessary absenteeism. Management of a child with croup should focus on reducing airway inflammation and supporting respiratory function. For mild croup, home management with humidified air and adequate hydration is often sufficient. For moderate to severe cases, a single dose of oral dexamethasone (0.15-0.6 mg/kg, maximum 10 mg) is the cornerstone of treatment, as it reduces inflammation and prevents return visits 1. In severe cases with stridor at rest or respiratory distress, nebulized epinephrine (racemic 2.25% solution 0.5 mL in 2.5 mL normal saline, or L-epinephrine 1:1000 solution 5 mL) provides temporary relief through vasoconstriction and reduced mucosal edema. Children receiving epinephrine should be observed for at least 2-3 hours as rebound symptoms may occur. Hospitalization is indicated for children with persistent stridor at rest, significant respiratory distress, hypoxemia (oxygen saturation <92%), or inadequate oral intake.

Some key points to consider in the management and exclusion guidelines for a child with croup include:

• The use of clinical guidelines and ordersets to reduce hospital admissions for croup, as shown in a study published in Pediatrics in 2022 2
• The importance of reducing the admission rate among patients who received 2 or fewer doses of racemic epinephrine, with a relative decrease of 57% (95% CI: 24 to 89) 3
• The sustained reductions in admission for croup over a year and a half into the pandemic, with a relative decrease of 37% (95% CI: 8 to 66) 4
• The focus on changing the number of racemic epinephrine doses prompting admission, a key element related to disposition determination in patients with croup.

Overall, the management of a child with croup should prioritize reducing airway inflammation, supporting respiratory function, and minimizing unnecessary school exclusion to improve the child's quality of life.

From the Research

Management of Croup

• Croup is a common respiratory illness affecting children, characterized by upper airway obstruction, inspiratory stridor, and a barking cough 5.
• Management of croup typically involves supportive care, with corticosteroids and nebulized epinephrine used in moderate to severe cases 5.
• Heliox, a mixture of helium and oxygen, has been used in some cases to relieve respiratory distress, but its effectiveness is still uncertain 6, 7, 8.

Exclusion Guidelines

• The decision to exclude a child with croup from school or daycare depends on the severity of symptoms and the risk of transmission to others.
• Children with mild croup may not need to be excluded, but those with moderate to severe symptoms may require exclusion until their symptoms improve 9.
• There is no specific evidence on exclusion guidelines for croup, but general guidelines for respiratory illnesses suggest excluding children who are unable to participate in activities or require frequent medical attention.

Treatment Options

• Corticosteroids, such as dexamethasone, are effective in reducing symptoms and improving outcomes in children with croup 5.
• Nebulized epinephrine may be used in addition to corticosteroids in moderate to severe cases 5.
• Heliox may be beneficial in the short term for children with moderate croup treated with dexamethasone, but its effectiveness is still uncertain 6, 7, 8.

School Exclusion Policies

• Schools and daycare centers should have policies in place for excluding children with respiratory illnesses, including croup.
• These policies should be based on the severity of symptoms and the risk of transmission to others.
• Children with croup should be excluded from school or daycare until their symptoms improve and they are no longer at risk of transmitting the illness to others.