Treatment of Croup in a 5-Year-Old with Shortness of Breath
The first-line treatment for a 5-year-old presenting with croup and shortness of breath is oral dexamethasone 0.6 mg/kg as a single dose, with the addition of nebulized epinephrine for moderate to severe respiratory distress. 1, 2, 3
Initial Assessment and Classification
When evaluating a child with croup and shortness of breath, assess the severity based on:
- Presence and severity of stridor (at rest or only with agitation)
- Work of breathing (presence of retractions)
- Respiratory rate (increased for age)
- Oxygen saturation (< 90% indicates severe disease)
- Level of alertness
Severity Classification:
- Mild: Barking cough, no stridor at rest, minimal retractions
- Moderate: Barking cough, audible stridor at rest, retractions, some distress
- Severe: Prominent stridor, marked retractions, significant distress, decreased air entry
Treatment Algorithm
1. For All Severity Levels:
- Administer oral dexamethasone 0.6 mg/kg as a single dose (maximum 10-12 mg) 3, 4
- This reduces inflammation, improves symptoms, and decreases the risk of return visits
- Effects begin within 1-2 hours and last up to 72 hours
2. For Moderate to Severe Respiratory Distress:
- Add nebulized epinephrine (racemic epinephrine 2.25%, 0.5 mL diluted in 2.5 mL saline) 1, 5
- Provides rapid but temporary relief (30 minutes to 2 hours)
- Monitor for at least 2 hours after administration for rebound symptoms
3. Alternative Corticosteroid Options:
- If unable to tolerate oral medication: Intramuscular dexamethasone 0.6 mg/kg 6, 4
- Alternative to dexamethasone: Nebulized budesonide 2 mg 1, 6
Supportive Care
- Ensure adequate hydration
- Keep the child calm (agitation can worsen symptoms)
- Position the child upright or in a comfortable position
- Provide supplemental oxygen if oxygen saturation is below 92%
Hospitalization Criteria
Hospitalize the child if:
- Requires more than one dose of nebulized epinephrine 5
- Has persistent severe respiratory distress despite treatment
- Has hypoxemia requiring supplemental oxygen
- Is unable to maintain adequate oral intake
- Appears toxic or significantly lethargic
- Has inadequate home care or difficulty accessing medical care if symptoms worsen 1
Important Considerations
- Avoid cough suppressants and OTC medications as they provide no benefit and may be harmful 1, 5
- Antibiotics have no proven effect on uncomplicated viral croup 5
- Cool mist or exposure to cold air lacks supporting evidence but is sometimes used empirically 2
- Avoid antihistamines and decongestants as they have no proven benefit 5
Follow-up
- For mild cases treated as outpatients, follow up within 24-48 hours
- Instruct parents to return immediately if:
- Increasing work of breathing
- Stridor at rest worsens or persists
- Child becomes lethargic or has decreased oral intake
- Symptoms worsen despite treatment
The evidence strongly supports corticosteroids as the mainstay of treatment for croup of any severity, with the addition of nebulized epinephrine for moderate to severe cases. This approach has been shown to reduce hospitalization rates, length of illness, and symptom severity.