Initial Management of Croup in Children
The initial management for a child presenting with croup should include early administration of a single dose of oral dexamethasone (0.15-0.6 mg/kg) for all patients regardless of severity, with the addition of nebulized epinephrine (0.5 ml/kg of 1:1000 solution) reserved for moderate to severe cases with respiratory distress. 1, 2, 3
Assessment and Diagnosis
Croup is characterized by:
- Barking cough
- Inspiratory stridor
- Hoarseness
- Often preceded by upper respiratory symptoms
- Most commonly affects children 6 months to 6 years of age 2
Key Diagnostic Features
- Sudden onset of respiratory distress with coughing, stridor, or wheezing
- Low-grade fever may be present but is not necessary for diagnosis
- Absence of fever or other respiratory symptoms (like antecedent cough or congestion) suggests possible foreign body aspiration rather than croup 1
Severity Assessment
Assess for signs of respiratory distress:
- Mild: Barking cough, no audible stridor at rest
- Moderate: Barking cough, audible stridor at rest, some suprasternal retractions
- Severe: Barking cough, prominent stridor, marked retractions, agitation or lethargy
Treatment Algorithm
Step 1: For ALL patients with croup (mild, moderate, or severe)
- Administer dexamethasone 0.15-0.6 mg/kg as a single dose (oral preferred) 2, 3, 4
- This reduces symptom severity, return visits, and hospitalization rates
Step 2: For moderate to severe croup
- Add nebulized epinephrine (0.5 ml/kg of 1:1000 solution) 1, 3
- Monitor for at least 2 hours after epinephrine administration due to potential rebound effect 5
- Provide supplemental oxygen if oxygen saturation is <94% 1
Step 3: Observation period
- For mild croup with good response to dexamethasone: can be discharged home
- For moderate croup: observe for 2 hours after treatment to ensure improvement
- For severe croup: consider up to 2 hours observation after each epinephrine dose with consideration for admission after 3 total doses 1
Special Considerations
When to Consider Hospital Admission
Consider admission if:
- Persistent stridor at rest after treatment
- Significant respiratory distress or retractions
- Need for more than 2 doses of nebulized epinephrine
- Hypoxemia (oxygen saturation <94%)
- Inability to tolerate oral fluids
- Toxic appearance or altered level of consciousness 1
When to Consider ICU Transfer
- Failing to maintain oxygen saturation >92% despite supplemental oxygen
- Severe respiratory distress with elevated PaCO2 (>6.5 kPa)
- Recurrent apnea or irregular breathing
- Evidence of encephalopathy 1
Common Pitfalls to Avoid
Unnecessary imaging: Radiography should be reserved for cases where alternative diagnoses are suspected 4
Overuse of nebulized epinephrine: Should be reserved for moderate to severe cases, not mild croup 1, 3
Discharge too early after epinephrine: Monitor for at least 2 hours after administration due to potential rebound effect 5
Failure to differentiate from other causes of stridor: Consider epiglottitis, bacterial tracheitis, foreign body aspiration, peritonsillar abscess, retropharyngeal abscess, and angioedema in the differential diagnosis 2
Using nebulized epinephrine in patients about to be discharged: The effect is short-lived (1-2 hours) and should not be used in children who are shortly to be discharged or on an outpatient basis 1
By following this evidence-based approach, most children with croup can be effectively managed, with only 1-8% requiring hospital admission and less than 3% of admitted patients requiring intubation 2.