Initial Management of Spasmodic Croup in Children
The initial management for a child with spasmodic croup should include a single dose of oral dexamethasone (0.15-0.60 mg/kg) even for mild cases, along with supportive care including keeping the child calm and in a comfortable upright position. 1
Understanding Spasmodic Croup
Spasmodic croup is characterized by sudden onset of respiratory distress without fever or preceding respiratory symptoms (unlike viral croup), typically presenting with:
- Barking cough
- Stridor (high-pitched breathing sound)
- Hoarse voice
- Respiratory distress that often worsens at night
Unlike viral croup, spasmodic croup occurs suddenly without viral prodrome 2. It's important to distinguish this from viral croup, which typically begins with low-grade fever and coryza before developing the characteristic barking cough 3.
Assessment of Severity
Severity assessment should be performed using the Westley Croup Score 1:
| Severity | Clinical Features | Score |
|---|---|---|
| Mild | Barking cough, no stridor at rest | 0-2 |
| Moderate | Stridor at rest, some retractions | 3-5 |
| Severe | Significant stridor, marked retractions, decreased air entry | 6-11 |
| Impending respiratory failure | Above plus cyanosis, altered consciousness | ≥12 |
Treatment Algorithm
1. For All Severity Levels:
- Corticosteroids: Administer a single dose of dexamethasone 0.15-0.60 mg/kg orally 1, 3
- This is recommended even for mild cases
- Alternative: Nebulized budesonide (2 mg) if child cannot tolerate oral medication 4
2. For Mild Croup (No stridor at rest):
- Keep the child calm and in a comfortable upright position
- Ensure adequate fluid intake
- Use fever-reducing medications if needed 1
3. For Moderate to Severe Croup (Stridor at rest, retractions):
- All treatments for mild croup PLUS:
- Nebulized epinephrine: 0.5 ml/kg of 1:1000 solution 1, 4
- Provides rapid but temporary relief of symptoms
- Monitor for rebound symptoms after epinephrine wears off (2-3 hours)
- Provide supplemental oxygen if oxygen saturation is <92% 1
Discharge vs. Admission Criteria
Safe for Discharge if:
- Significant improvement in symptoms
- No stridor at rest after treatment
- Can tolerate oral fluids
- No repeated doses of epinephrine required
- Oxygen saturation ≥92% on room air 1
Consider Admission if:
- 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
- Children requiring two epinephrine treatments should be hospitalized 5
Important Considerations
Differential Diagnosis: Always consider other causes of stridor including epiglottitis, foreign body aspiration, retropharyngeal abscess, bacterial tracheitis, and congenital anomalies 1
Avoid Ineffective Treatments:
Recurrent Episodes: Children with recurrent croup (defined as two or more episodes per year) should be evaluated for underlying structural or inflammatory airway abnormalities 2
Parental Education: Instruct parents to return to the emergency department if the child develops increased work of breathing, lethargy, or inability to drink fluids 1