From the Guidelines
Croup in a 6-year-old is typically diagnosed clinically based on the characteristic barking cough, stridor, and respiratory distress, without requiring specific testing in most cases, and treatment depends on severity, with a single dose of oral dexamethasone being the cornerstone of treatment for moderate to severe symptoms. The diagnosis of croup is primarily clinical, relying on the presence of a barking cough, stridor, and signs of respiratory distress, as noted in the management of pediatric respiratory conditions 1.
Testing
Testing such as lateral neck radiographs is not routinely necessary for the diagnosis of croup, and their use can vary significantly between institutions, with one study finding that the median percentage of patients with a lateral neck radiograph was 21% across different children’s hospitals in the United States 1. For children over 6 years, spirometry can be a useful tool in assessing respiratory function, especially in the context of chronic cough or when there are concerns about underlying respiratory disease, as highlighted in guidelines for managing chronic cough in children 1.
Treatment
Treatment of croup is guided by the severity of symptoms. Mild cases can be managed at home with cool mist humidification and upright positioning. For moderate to severe cases, a single dose of oral dexamethasone (0.6 mg/kg, maximum 10 mg) is recommended, as it reduces inflammation in the upper airway and improves symptoms within hours. In severe cases with significant respiratory distress, nebulized epinephrine may be administered in an emergency setting, followed by observation for at least 2-3 hours due to potential symptom rebound. Hospitalization is indicated for children with persistent stridor at rest, significant respiratory distress, hypoxemia, or those requiring multiple epinephrine treatments. Antibiotics are not indicated for croup unless there is evidence of a secondary bacterial infection, as croup is typically viral in nature.
Management and Follow-Up
Most children with croup improve within 3-5 days, though the cough may persist longer. Parents should be advised to seek immediate medical attention if the child develops signs of severe respiratory distress, such as blue lips, severe difficulty breathing, drooling, or inability to drink fluids. The use of clinical guidelines and order sets, as shown in a study from 2022, can help reduce hospital admissions for croup by ensuring that children receive appropriate and timely treatment, thereby improving outcomes and reducing healthcare utilization 1.
From the Research
Testing for Croup
- Laboratory studies are seldom needed for diagnosis of croup 2
- Viral cultures and rapid antigen testing have minimal impact on management and are not routinely recommended 2
- Radiography and laryngoscopy should be reserved for patients in whom alternative diagnoses are suspected 2
Treatment Options
- Glucocorticoids are effective by oral, parenteral or nebulized routes, and continue to provide the mainstay of therapy 3
- 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 2
- In patients with moderate to severe croup, the addition of nebulized epinephrine improves symptoms and reduces length of hospitalization 2
- For mild to moderate croup, prednisolone 1.0 mg/kg can be given and reviewed in 1 hour 4
- In severe or life-threatening croup, adrenaline 1:1000 (undiluted) via nebuliser can be given and the child should be sent immediately to hospital via ambulance 4
- Dexamethasone, given orally as a single dose at 0.6 mg/kg, is highly efficacious in treating croup symptoms 5
Assessment and Management
- The assessment of airway, breathing and circulation, focusing on airway, is paramount in treating croup 4
- More liberal use of systemic corticosteroids for croup has been associated with reduced rates of hospital admission, reduced admissions to the intensive care unit and a reduced need for endotracheal intubation 6
- Published guidelines for the diagnosis and treatment of croup advise using steroids as the mainstay treatment for all children who present to emergency department (ED) with croup symptoms 5