What is the first line treatment for a child presenting with croup?

First-Line Treatment for Croup in Children

The first-line treatment for a child presenting with croup is a single dose of oral dexamethasone (0.15-0.60 mg/kg), which is recommended for all children with croup regardless of severity. 1

Understanding Croup

Croup is a common respiratory illness affecting approximately 3% of children between 6 months and 3 years of age, characterized by:

• Barking cough
• Hoarse voice
• Stridor (especially when breathing in)
• Variable degrees of respiratory distress
• Symptoms often worsen at night

Assessment of Severity

The Westley Croup Score is the recommended tool to determine severity:

Parameter	0 points	1 point	2 points	3 points	4 points	5 points
Stridor	None	When agitated	At rest	-	-	-
Retractions	None	Mild	Moderate	Severe	-	-
Air entry	Normal	Decreased	Markedly decreased	-	-	-
Cyanosis	None	-	-	With agitation	At rest	-
Level of consciousness	Normal	-	-	-	-	Altered

Severity classification:

• Mild: Score 0-2 (barking cough, no stridor at rest)
• Moderate: Score 3-5 (stridor at rest, some chest wall retractions)
• Severe: Score 6-11 (significant stridor at rest, significant retractions, decreased air entry)
• Impending respiratory failure: Score ≥12

Treatment Algorithm

1. First-Line Treatment (All Severity Levels)

• Corticosteroids: Single dose of dexamethasone 0.15-0.60 mg/kg orally 1, 2
  • Lower dose (0.15 mg/kg) has been shown to be effective 3
  • Benefits observed as early as 30 minutes after administration 3

2. Additional Treatment for Moderate to Severe Croup

• Nebulized epinephrine: 0.5 ml/kg of 1:1000 solution 1, 4
  • Provides rapid but temporary relief of symptoms
  • Children requiring two or more epinephrine treatments should be hospitalized 5

3. Supportive Care

• Keep the child calm and in a comfortable position (preferably upright)
• Ensure adequate hydration
• Provide supplemental oxygen if saturation is <92%
• Manage fever with appropriate antipyretics

Important Clinical Considerations

• Evidence against common interventions:

  • Humidification therapy has not been proven beneficial 2
  • Antihistamines, decongestants, and antibiotics have no proven effect on uncomplicated viral croup 5

• When to consider hospital admission:

  • Oxygen saturation <92% or cyanosis
  • Persistent significant respiratory distress 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

• Discharge criteria:

  • Significant improvement in symptoms
  • No stridor at rest
  • Ability to tolerate oral fluids
  • No repeated doses of epinephrine required
  • Oxygen saturation ≥92% on room air 1

Differential Diagnosis Considerations

Always consider other causes of stridor that may mimic croup:

• Epiglottitis
• Foreign body aspiration
• Retropharyngeal abscess
• Bacterial tracheitis
• Airway hemangioma
• Congenital anomalies of the larynx

Proper identification of the cause of stridor is essential as treatment approaches differ significantly between these conditions.