What is the best treatment for croup?

From the Guidelines

The best treatment for croup is a single dose of oral dexamethasone (0.15-0.6 mg/kg, maximum 10 mg) for moderate to severe cases, as it reduces inflammation in the upper airway, with hospitalization necessary for children with persistent stridor at rest, respiratory distress, or oxygen requirements, as supported by recent studies 1.

Treatment Approach

The treatment approach for croup depends on its severity, with mild cases often managed at home with cool mist humidification and keeping the child calm. For moderate to severe cases, a single dose of oral dexamethasone is the mainstay of treatment. In severe cases with respiratory distress, nebulized epinephrine may be given in an emergency setting, followed by observation for at least 2-3 hours as symptoms can return.

Key Considerations

• Hospitalization is necessary for children with persistent stridor at rest, respiratory distress, or oxygen requirements.
• The use of a clinical guideline and orderset can help reduce hospital admissions for croup, as shown in a study published in Pediatrics 1.
• A significant decrease in hospital admissions with no increase in revisits was associated with croup quality improvement interventions, as reported in another study 1.
• The implementation of a local clinical guideline was the key strategy for improvement, with a 37% relative reduction in hospital admission following ED encounters for croup, as noted in a study 1.

Treatment Details

• Oral dexamethasone: 0.15-0.6 mg/kg, maximum 10 mg, as a single dose for moderate to severe cases.
• Nebulized epinephrine: racemic epinephrine 2.25% 0.5 mL in 2.5 mL saline, or L-epinephrine 1:1000 5 mL, may be given in an emergency setting for severe cases with respiratory distress.
• Cool mist humidification and keeping the child calm are often sufficient for mild cases.

From the Research

Treatment Options for Croup

• The primary treatment for croup involves the use of glucocorticoids, which are effective in decreasing symptoms and reducing inflammation 2.
• A single dose of oral, intramuscular, or intravenous dexamethasone has been shown to improve symptoms and reduce return visits and length of hospitalization in children with croup of any severity 3.
• For patients with moderate to severe croup, the addition of nebulized epinephrine can improve symptoms and reduce length of hospitalization 3.
• Heliox may also be effective in the short-term management of refractory croup, although further study is warranted 2, 4.
• The use of humidified oxygen remains controversial, with some studies suggesting it provides no demonstrable benefit in the acute setting 5.

Medication Dosage and Administration

• A 0.15 mg/kg dose of oral dexamethasone may be as effective as larger doses, such as 0.6 mg/kg 5.
• Nebulized racemic or L-epinephrine can reduce the severity of symptoms in moderate-to-severe croup 5.
• The administration of Heliox has been shown to result in similar improvements in croup scores compared to patients given racemic epinephrine 4.

Treatment Effectiveness and Safety

• Corticosteroids, such as dexamethasone, have been found to be effective in reducing symptoms and improving outcomes in children with croup 6, 3.
• Nebulized epinephrine and Heliox have also been shown to be effective in reducing symptoms and improving outcomes in children with moderate to severe croup 6, 4.
• The safety of these treatments has been evaluated, with corticosteroids and nebulized epinephrine found to be generally safe and effective 6, 3.