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

First-Line Treatment for Croup in Children

Corticosteroids, specifically a single dose of dexamethasone (0.15-0.60 mg/kg orally), are the first-line treatment for all children with croup, regardless of severity. 1

Assessment of Severity

Before initiating treatment, assess the severity of croup using the Westley Croup Score:

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

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

Treatment Algorithm

For All Severity Levels:

1. Dexamethasone 0.15-0.60 mg/kg orally as a single dose 1, 2
   • This is the cornerstone of treatment for all croup cases
   • Benefits are seen even in mild cases
   • Reduces inflammation and improves symptoms

For Moderate to Severe Croup (Additional Treatment):

1. Nebulized epinephrine (0.5 ml/kg of 1:1000 solution) 1, 2
   • Provides rapid but temporary relief of airway obstruction
   • Monitor for at least 2-3 hours after administration for rebound symptoms
   • Need for repeated doses indicates consideration for hospital admission

Supportive Care:

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

Important Clinical Considerations

• Cool mist humidification has limited evidence for benefit but is commonly recommended 1
• Antibiotics, antihistamines, and decongestants have no proven benefit in uncomplicated viral croup and should not be used 3
• Heliox may be considered in severe cases to reduce work of breathing, though evidence is limited 1

Admission Criteria

Consider hospital admission if any of the following are present:

• 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

Discharge Criteria

Patients can be safely discharged when:

• Significant improvement in symptoms is observed
• No stridor at rest persists after treatment
• Patient can tolerate oral fluids
• No repeated doses of epinephrine are required
• Oxygen saturation remains ≥92% on room air

Common Pitfalls to Avoid

1. Failure to consider differential diagnoses: Always consider other causes of stridor that may mimic croup, including epiglottitis, foreign body aspiration, bacterial tracheitis, and retropharyngeal abscess.

2. Undertreatment of mild cases: Even mild croup benefits from corticosteroid treatment.

3. Causing undue distress: Avoid procedures that may agitate the child, as this can worsen airway obstruction.

4. Inadequate monitoring: Children with moderate to severe croup require close monitoring for signs of deterioration, including increased work of breathing, lethargy, or cyanosis.

5. Unnecessary antibiotic use: Croup is typically viral, and antibiotics are not indicated unless a bacterial complication is suspected.