What is the management of croup in pediatric patients?

From the Guidelines

The management of croup in pediatric patients should prioritize supportive care, reduction of airway inflammation, and judicious use of medications, with a focus on reducing hospital admissions as evidenced by a 37% relative reduction achieved through a clinical guideline and orderset implementation 1. The cornerstone of treatment for croup involves the use of a single dose of oral dexamethasone, which has been shown to reduce inflammation and improve symptoms within hours. Key considerations in the management of croup include:

• For mild cases, humidified air and keeping the child calm may be sufficient.
• For moderate to severe cases, oral dexamethasone (0.15-0.6 mg/kg, maximum 10 mg) is recommended.
• In severe cases with respiratory distress, nebulized epinephrine can provide temporary relief.
• Supplemental oxygen should be provided if oxygen saturation falls below 92%.
• Hospitalization is necessary for those with persistent stridor at rest, respiratory distress, hypoxemia, or inability to maintain hydration.
• Antibiotics are not indicated as croup is typically viral.
• Parent education on the characteristic barking cough, potential worsening of symptoms at night, and when to seek immediate medical attention is crucial. The implementation of a clinical guideline and orderset, as described in a recent study 1, can significantly reduce hospital admissions for croup, highlighting the importance of evidence-based management strategies in pediatric care.

From the Research

Management of Croup in Pediatric Patients

The management of croup in pediatric patients typically involves supportive care and treatment with corticosteroids and nebulised epinephrine (adrenaline) in moderate to severe cases 2, 3.

• Mild Croup: Most children with mild croup can be managed at home with supportive care, and a single dose of oral corticosteroid may be indicated if there are risk factors for hospital admission 4.
• Moderate to Severe Croup: Children with moderate to severe croup should be reviewed in an emergency department and may need hospital admission. Treatment with oral, intramuscular, or intravenous dexamethasone improves symptoms and reduces return visits and length of hospitalization 3, 5.
• Heliox Inhalation: There is some evidence to suggest a short-term benefit of heliox inhalation in children with moderate to severe croup who have been administered oral or intramuscular dexamethasone 2.
• Nebulized Epinephrine: The addition of nebulized epinephrine improves symptoms and reduces length of hospitalization in patients with moderate to severe croup 3.
• Home Care: Home care consists of adequate hydration and humidification, and fever control. Antihistamines, decongestants, and antibiotics have no proven effect on uncomplicated viral croup 6.

Treatment Options

• Dexamethasone: 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, 5.
• Nebulized Epinephrine: Nebulized epinephrine may be used in addition to dexamethasone in patients with moderate to severe croup 3.
• Heliox: Heliox inhalation may be used in children with moderate to severe croup who have been administered oral or intramuscular dexamethasone 2.

Important Considerations

• Assessment: Assessment of the child's condition is crucial in determining the severity of croup and the need for hospital admission 4.
• Monitoring: Close monitoring of the child's condition is necessary to ensure that the treatment is effective and to detect any potential complications 3.