What is the treatment for croup?

Treatment of Croup

For all patients with croup, regardless of severity, administer dexamethasone 0.15-0.60 mg/kg orally as a single dose to reduce symptoms, prevent return visits, and decrease length of hospitalization. 1

Assessment and Classification

Assess croup severity based on these clinical features:

• Mild: Barking cough, no audible stridor at rest, minimal or no respiratory distress
• Moderate: Barking cough, audible stridor at rest, visible retractions
• Severe: Prominent inspiratory and expiratory stridor, significant respiratory distress, agitation or lethargy

Treatment Algorithm

For All Patients with Croup:

• Administer dexamethasone 0.15-0.60 mg/kg orally as a single dose 1
  • Maximum dose: 10-12 mg 2
  • For mild cases, lower doses (0.15-0.30 mg/kg) may be sufficient 2
  • For patients unable to tolerate oral medication due to vomiting or severe respiratory distress, use intramuscular dexamethasone at the same dose 1, 3

For Moderate to Severe Croup:

• Add nebulized epinephrine (0.5 ml/kg of 1:1000 solution) 1
• Observe for at least 2-3 hours after epinephrine administration to monitor for rebound symptoms 1
• Consider hospital admission after 3 total doses of nebulized epinephrine 1

Supportive Care:

• Maintain a calm environment
• Position child comfortably
• Ensure adequate hydration
• Provide supplemental oxygen if saturation is <92% 1

Indications for Hospital Admission

Consider admission for patients with:

• Oxygen saturation <92% or cyanosis
• Significant respiratory distress persisting 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 Clinical Considerations

• Avoid premature discharge: Patients who receive nebulized epinephrine should be observed for at least 2-3 hours 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 benefit in uncomplicated viral croup 4
• Humidification therapy has not been proven beneficial 5
• Most croup cases resolve within 2 days, with only 1-8% requiring hospital admission 1, 5

Follow-up Care

• Review children if symptoms are not improving after 48 hours 1
• Educate parents about the potential for symptom recurrence and when to seek medical attention

The evidence strongly supports corticosteroid use in croup management, with dexamethasone being the preferred agent due to its ease of administration, availability, and low cost 2. While nebulized budesonide (2 mg) can be an alternative for children who cannot tolerate oral dexamethasone 6, oral administration is generally preferred when possible 3.