From the Guidelines
The recommended treatment for croup depends on its severity, with a focus on reducing inflammation and improving symptoms, as evidenced by recent studies 1. For mild croup, home management with humidified air (using a cool-mist humidifier or sitting in a steamy bathroom) and keeping the child calm is often sufficient.
- Key considerations include:
- Monitoring oxygen saturation levels
- Providing oxygen if saturation falls below 92%
- Avoiding antibiotics, as croup is typically viral
- For moderate to severe croup, a single dose of oral dexamethasone (0.15-0.6 mg/kg, maximum 10 mg) is the mainstay of treatment, as it reduces inflammation in the airway and improves symptoms within hours, as supported by the most recent and highest quality study 1. In severe cases with respiratory distress, nebulized epinephrine (racemic epinephrine 2.25% solution, 0.5 mL in 2.5 mL saline, or L-epinephrine 1:1000,5 mL) may be administered in an emergency setting, followed by observation for at least 2-3 hours as symptoms can recur 1. Parents should seek immediate medical attention if the child develops increased work of breathing, inability to swallow, or appears blue or pale, as these symptoms can indicate a more severe condition requiring prompt intervention 1.
From the Research
Treatment for Croup
The recommended treatment for croup typically involves a combination of medications and supportive care.
- A single dose of systemic dexamethasone is often combined with nebulized epinephrine to treat croup 2.
- The optimal dose of nebulized epinephrine remains unclear, but studies have shown that low-dose (0.1 mg/kg) nebulized epinephrine is not inferior to the conventional dose (0.5 mg/kg) in reducing croup scores in patients with moderate to severe croup 2.
- Nebulized saline solution and oral or intramuscular dexamethasone (0.6 mg/kg) can also be effective in treating croup, with nebulized racemic epinephrine (0.5 mL of 2.25% solution diluted in 2.5 mL of saline solution) used occasionally 3.
- A single dose of dexamethasone (0.15 to 0.60 mg per kg) is recommended in all patients with croup, including those with mild disease, and nebulized epinephrine is an accepted treatment in patients with moderate to severe croup 4.
- Oral dexamethasone can be effectively and safely used for the outpatient treatment of moderate croup, with no statistically significant difference found in the need for subsequent interventions after a single dose of either intramuscular or oral dexamethasone 5.
- Nebulized epinephrine has been associated with a clinically and statistically significant transient reduction of symptoms of croup 30 minutes post-treatment, and is associated with a shorter hospital stay than placebo 6.
Medications and Dosages
- Dexamethasone: 0.6 mg/kg (maximum 8 mg) orally or intramuscularly 3, 5.
- Nebulized epinephrine: 0.1 mg/kg (maximum 1 mg) or 0.5 mg/kg (maximum 5 mg) 2.
- Racemic epinephrine: 0.5 mL of 2.25% solution diluted in 2.5 mL of saline solution 3.