What is the recommended dose of adrenaline (epinephrine) nebulisation for children with croup?

Adrenaline (Epinephrine) Nebulization Dosing for Children with Croup

For children with croup, the recommended dose of nebulized epinephrine is 0.5 mL/kg of 1:1000 solution (maximum: 5 mL = 5 mg) administered by nebulizer. 1

Dosing Options and Formulations

L-Epinephrine (Standard Epinephrine)

• Dose: 0.5 mL/kg of 1:1000 solution (maximum: 5 mL = 5 mg) 1
• This is the most commonly available form of epinephrine

Racemic Epinephrine

• Dose: 0.05 mL/kg of 2.25% solution (maximum: 0.5 mL) in 2 mL of normal saline 1
• Many institutions use a standard 0.5 mL dose of racemic epinephrine for all patients regardless of weight 1
• If racemic epinephrine is not available, L-epinephrine (1:1000) can be substituted at the dose mentioned above 1

Clinical Considerations

When to Use Nebulized Epinephrine

• Indicated for moderate to severe croup cases 2
• Used to avoid intubation and stabilize children prior to transfer to intensive care 1
• Effective for stridor following intubation 1

Duration of Effect and Monitoring

• Effect is short-lived (1-2 hours) 1, 2
• Patients should be observed for at least 2 hours after administration to monitor for rebound symptoms 2

Important Cautions

• Should not be used in children who are shortly to be discharged or on an outpatient basis 1
• Children requiring two or more epinephrine treatments should be considered for hospitalization 3

Treatment Algorithm

1. Assess croup severity:

   • Mild: Barking cough, no audible stridor at rest, minimal respiratory distress
   • Moderate: Barking cough, audible stridor at rest, some respiratory distress
   • Severe: Prominent stridor, significant respiratory distress, agitation or lethargy

2. Treatment based on severity:

   • Mild: Dexamethasone alone (0.15-0.60 mg/kg orally) 2
   • Moderate to severe: Dexamethasone plus nebulized epinephrine 2

3. Administer nebulized epinephrine:

   • L-epinephrine: 0.5 mL/kg of 1:1000 solution (maximum: 5 mL) 1
   • OR Racemic epinephrine: 0.05 mL/kg of 2.25% solution (maximum: 0.5 mL) in 2 mL normal saline 1

4. Monitor response:

   • Observe for at least 2 hours after administration 2
   • Assess for rebound symptoms
   • Consider hospitalization if:
     • Oxygen saturation <92%
     • Persistent respiratory distress after treatment
     • Persistent stridor at rest after treatment
     • Need for more than one dose of nebulized epinephrine 2

Evidence Quality and Considerations

The dosing recommendations are primarily based on guidelines from the American Academy of Pediatrics 1 and British Thoracic Society 1. Evidence suggests no significant difference in efficacy between racemic epinephrine and L-epinephrine 4, so either formulation can be used based on availability.

Research shows that nebulized epinephrine provides clinically significant reduction in croup symptoms at 30 minutes post-treatment 4, making it valuable for acute management, but the short duration of action necessitates close monitoring for symptom recurrence.