Treatment of Croup in Children
The optimal treatment for a child with croup includes a single dose of oral dexamethasone (0.15-0.60 mg/kg) for all severities of croup, with the addition of nebulized epinephrine (0.5 mL/kg of 1:1000 solution, maximum 5 mL) 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 of age (peak in second year) 1
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 1
Treatment Algorithm
Step 1: For ALL children with croup (mild, moderate, severe)
- Administer dexamethasone 0.15-0.60 mg/kg orally as a single dose 1
- This reduces symptoms, return visits, and length of hospitalization
- Even mild croup benefits from corticosteroid treatment 2
Step 2: For moderate to severe croup
- Add nebulized epinephrine 1
- Dosage: 0.5 mL/kg of 1:1000 solution (maximum: 5 mL = 5 mg)
- 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 a calm environment
- Position child comfortably (often upright)
- Ensure adequate hydration
- Provide supplemental oxygen if saturation is <92% 1
Important Considerations
Monitoring
- Monitor respiratory rate, work of breathing, and oxygen saturation
- Watch for signs of deterioration: increased work of breathing, lethargy, or cyanosis 1
Nebulized Epinephrine Precautions
- Effect is short-lived (1-2 hours)
- Observe for at least 2-3 hours after administration to monitor for rebound symptoms
- Consider hospital admission after 3 total doses 1
Alternative to Oral Dexamethasone
- Nebulized budesonide (2 mg) can be used for children who cannot tolerate oral dexamethasone 3
Hospital Admission Criteria
Consider hospital admission if any of the following are present:
- Oxygen saturation <92% or cyanosis
- Significant respiratory distress that persists after treatment
- Stridor at rest that persists after treatment
- Need for more than one dose of nebulized epinephrine
- Inability to tolerate oral fluids
- Toxic appearance 1
Common Pitfalls to Avoid
- Avoiding corticosteroids in mild cases - Evidence shows benefit across all severity levels 2
- Discharging too soon after epinephrine - Monitor for at least 2-3 hours due to potential rebound symptoms 1
- Routine imaging - Avoid unless there is suspicion of alternative diagnosis or failure to respond to standard therapy 1
- Humidification therapy - Has not been proven beneficial 2
- Overlooking alternative diagnoses - Consider bacterial tracheitis, epiglottitis, foreign body aspiration if not responding to standard treatment 4
Most croup cases resolve within 2 days, with only 1-8% requiring hospital admission 1, 2. The prognosis is generally excellent with appropriate treatment.