What is the recommended treatment for croup?

Treatment for Croup

Dexamethasone (0.15-0.60 mg/kg) as a single oral dose is recommended for all severities of croup, with nebulized epinephrine (0.5 ml/kg of 1:1000 solution) reserved for moderate to severe cases. 1

Clinical Presentation and Assessment

• Croup is characterized by a sudden onset of barking cough, inspiratory stridor, hoarse voice, and respiratory distress
• Most common in children 6 months to 6 years of age, with peak incidence in the second year of life
• Severity ranges from mild (barking cough, no audible stridor at rest, minimal respiratory distress) to severe (prominent stridor at rest, significant respiratory distress, agitation or lethargy)

Treatment Algorithm

For All Croup Cases:

1. Corticosteroids: Dexamethasone 0.15-0.60 mg/kg as a single oral dose 1, 2
   • Reduces symptoms, return visits, and length of hospitalization
   • Oral administration is as effective as intramuscular for outpatient management 3
   • Alternative: Nebulized budesonide (2 mg) for children who cannot tolerate oral dexamethasone 4

For Moderate to Severe Croup (stridor at rest, increased work of breathing):

1. Nebulized epinephrine: 0.5 ml/kg of 1:1000 solution 1
   • Effect is short-lived (1-2 hours)
   • Patients must be observed for at least 2 hours after administration to monitor for rebound symptoms
   • Consider hospital admission after 3 total doses 5, 1

Supportive Care:

• Maintain a calm environment
• Position child comfortably
• Ensure adequate hydration
• Provide supplemental oxygen if saturation is <92%

Hospital Admission Criteria

Consider admission for patients with:

• Oxygen saturation <92% or cyanosis
• Significant respiratory distress that persists after treatment
• Stridor at rest that persists after treatment
• Inability to tolerate oral fluids
• Toxic appearance
• Need for more than one dose of nebulized epinephrine 1

Important Considerations

• Observe patients for at least 2-3 hours after epinephrine administration before discharge to monitor for rebound symptoms 1
• Avoid routine imaging unless there is suspicion of an alternative diagnosis or failure to respond to standard therapy 1
• Antihistamines, decongestants, and antibiotics have no proven effect on uncomplicated viral croup 6
• Humidification therapy (cool mist) has not been proven beneficial 7, 4

Follow-up Care

• Children discharged home should be reviewed if symptoms are not improving after 48 hours 1
• Most croup cases resolve within 2 days, with only 1-8% requiring hospital admission 7

The evidence strongly supports dexamethasone as the cornerstone of croup treatment, with nebulized epinephrine reserved for more severe cases. This approach has been shown to effectively reduce symptom severity and healthcare utilization while maintaining patient safety.