From the Guidelines
UK guidelines for croup recommend a stepwise approach to management based on severity, with nebulised adrenaline and steroids being considered for moderate to severe cases, as supported by the British Thoracic Society guidelines 1. The management of croup typically involves assessing the severity of the condition and providing appropriate treatment.
- For mild croup, supportive care with reassurance and antipyretics if febrile is advised.
- For moderate to severe croup, a single oral dose of dexamethasone may be considered as the first-line treatment.
- In hospital settings, nebulized adrenaline (0.5 ml/kg of a 1:1000 solution) may be used to avoid intubation, to stabilise children prior to transfer to intensive care, and in stridor following intubation, as recommended by the British Thoracic Society guidelines 1.
- Additionally, nebulised steroids (for example, 500 µg budesonide) may also reduce symptoms in croup in the first two hours, as suggested by the British Thoracic Society guidelines 1.
- Oxygen should be provided if saturation falls below 92%, and antibiotics are not routinely recommended as croup is typically viral.
- Parents should be advised that symptoms often worsen at night and may last 3-7 days, and they should seek urgent medical attention if the child develops increased work of breathing, decreased oral intake, lethargy, or bluish discoloration.
- The use of clinical guidelines, such as limiting hospital admission until 3 doses of racemic epinephrine are needed, has been shown to reduce hospital admissions for croup without significant increase in revisits or readmissions, as demonstrated by a study published in Pediatrics 1.
From the Research
UK Guidelines for the Management of Croup
The management of croup, also known as acute laryngotracheobronchitis, involves the use of corticosteroids and other treatments to reduce symptoms and inflammation.
- Corticosteroids are the primary treatment option for croup, and can be given orally, parenterally, or in wet nebulised form 2, 3.
- In mild to moderate cases of croup, either systemic or nebulised corticosteroids can decrease symptoms and need for hospitalisation 2.
- A single dose of oral, intramuscular, or intravenous dexamethasone can improve symptoms and reduce return visits and length of hospitalization in children with croup of any severity 4.
- In patients with moderate to severe croup, the addition of nebulized epinephrine can improve symptoms and reduce length of hospitalization 5, 4.
Treatment Options
- Oral dexamethasone 0.15 mg/kg or nebulised budesonide 2 mg are effective for mild to moderate croup 2.
- In severe croup requiring intubation, oral prednisolone 1 mg/kg every 12 hours can decrease the duration of intubation and the need for re-intubation 2.
- Nebulised L-epinephrine in combination with intramuscular dexamethasone or nebulised budesonide can improve croup scores and reduce hospitalisation rates in patients with moderate to severe croup 5.
Assessment and Management
- Croup affects about 2% of preschool-aged children every year, and most children have mild croup and are managed at home 6.
- A minority of children develop moderate or severe croup and should be reviewed in an emergency department and may need hospital admission 6.
- Laboratory studies are seldom needed for diagnosis of croup, and viral cultures and rapid antigen testing have minimal impact on management 4.