Treatment of Croup
The cornerstone of croup treatment is a single dose of dexamethasone (0.15-0.60 mg/kg orally) for all children with croup, regardless of severity, along with nebulized epinephrine (0.5 ml/kg of 1:1000 solution) for moderate to severe cases. 1
Assessment of Severity
Before initiating treatment, assess croup severity using the Westley Croup Score:
| Severity | Score | Clinical Features |
|---|---|---|
| Mild | 0-2 | Barking cough, no stridor at rest |
| Moderate | 3-5 | Stridor at rest, some chest wall retractions |
| Severe | 6-11 | Significant stridor at rest, significant retractions, decreased air entry |
| Impending respiratory failure | ≥12 | Above plus cyanosis and altered consciousness |
Treatment Algorithm
For All Patients with Croup (Any Severity)
- Corticosteroids: Administer dexamethasone 0.15-0.60 mg/kg as a single oral dose 1, 2
- This reduces inflammation and improves symptoms with high-quality evidence
- Effective even in mild cases
- Takes approximately 6 hours for full effect 3
For Moderate to Severe Croup (Additional Therapy)
Nebulized epinephrine: 0.5 ml/kg of 1:1000 solution 1
Oxygen therapy: Provide supplemental oxygen if saturation <92% 1
Heliox: Consider for severe cases to reduce work of breathing (low strength of evidence) 1
Supportive Care Measures
- Maintain a calm environment (agitation can worsen symptoms)
- Position child upright or in a comfortable position
- Ensure adequate hydration
- Control fever with appropriate antipyretics if needed
- Monitor respiratory rate, work of breathing, and oxygen saturation 1
Important note: While cool mist humidification is commonly used, evidence for its benefit is limited 1, 2
Discharge and Admission Criteria
Safe for Discharge When:
- Significant improvement in symptoms
- No stridor at rest after treatment
- Patient can tolerate oral fluids
- No repeated doses of epinephrine required
- Oxygen saturation ≥92% on room air 1
Consider Hospital 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
Common Pitfalls and Caveats
Misdiagnosis: Always consider differential diagnoses that may mimic croup:
Underdosing steroids: Using too low a dose of dexamethasone can be ineffective 3
Inadequate monitoring: After nebulized epinephrine, patients must be observed for at least 2 hours for rebound symptoms 3
Unnecessary testing: Laboratory studies, viral cultures, and rapid antigen testing have minimal impact on management and are not routinely recommended 5
Overreliance on humidification: Despite common practice, humidification therapy has not been proven beneficial 2
Most croup cases are mild and self-limiting, with only 1-8% requiring hospital admission and less than 3% of admitted patients needing intubation 2. However, prompt and appropriate treatment significantly reduces morbidity and improves outcomes for children with croup 6.