What is the recommended treatment for croup in pediatric (peds) patients?

Treatment of Croup in Pediatric Patients

The recommended first-line treatment for croup in pediatric patients of all severity levels is a single dose of oral dexamethasone (0.15-0.60 mg/kg), with nebulized epinephrine (0.5 mL/kg of 1:1000 solution, maximum 5 mL) reserved for moderate to severe cases. 1

Diagnosis and Assessment

Croup is characterized by:

• Barking cough
• Inspiratory stridor
• Hoarse voice
• Respiratory distress
• Most common in children 6 months to 6 years (peak in second year of life)

Severity Assessment

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

Treatment Algorithm

Step 1: For ALL severity levels of croup

• Administer dexamethasone 0.15-0.60 mg/kg orally as a single dose 1
  • Lower dose (0.15 mg/kg) has been shown to be as effective as higher doses (0.6 mg/kg) for moderate to severe croup 2
  • Benefits begin as early as 30 minutes after administration, much earlier than previously thought 3

Step 2: For moderate to severe croup (stridor at rest, increased work of breathing)

• Add nebulized epinephrine 1, 4
  • Dose: 0.5 mL/kg of 1:1000 solution (maximum: 5 mL = 5 mg) OR
  • Alternative: 0.05 mL/kg of 2.25% racemic epinephrine solution (maximum: 0.5 mL) in 2 mL normal saline

Step 3: Supportive care

• Maintain calm environment
• Position child comfortably (often in parent's arms)
• Ensure adequate hydration
• Provide supplemental oxygen if saturation <92%

Important Clinical Considerations

Monitoring After Treatment

• The effect of nebulized epinephrine is short-lived (1-2 hours)
• Observe for at least 2-3 hours after epinephrine administration to monitor for rebound symptoms 1
• Consider admission after 3 total doses of nebulized epinephrine 1

Indications for Hospital Admission

• Oxygen saturation <92% or cyanosis
• Persistent significant respiratory distress after treatment
• Persistent stridor at rest after treatment
• Inability to tolerate oral fluids
• Toxic appearance
• Need for more than one dose of nebulized epinephrine

What NOT to Do

• Avoid routine imaging unless suspecting alternative diagnosis or failure to respond to standard therapy
• Avoid humidification therapy as it has not been proven beneficial 5
• Avoid nebulized epinephrine for children who will be discharged shortly due to risk of rebound symptoms 1

Prognosis

• Most cases resolve within 2 days
• Only 1-8% of cases require hospital admission
• Less than 3% of admitted patients require intubation 5, 4

Differential Diagnosis

Croup must be differentiated from:

• Epiglottitis (rapid onset, dysphagia, drooling)
• Bacterial tracheitis
• Foreign body aspiration (no viral prodrome, no fever, sudden onset)
• Peritonsillar abscess
• Retropharyngeal abscess
• Angioedema

The evidence strongly supports that even mild cases of croup benefit from corticosteroid treatment, which reduces symptom severity, return visits, and length of hospitalization when admission is required 1, 4.