What is the first line 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 and Severity Classification

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

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, significant retractions, decreased air entry)
• Impending respiratory failure: Score ≥12

Treatment Algorithm

For All Croup Patients (Mild, Moderate, and Severe):

1. Administer dexamethasone 0.15-0.60 mg/kg as a single oral dose 1, 2
   • This is effective even in mild cases
   • Onset of action is approximately 6 hours after administration 3
   • If oral administration is not possible, intramuscular or intravenous routes are equally effective 4

For Moderate to Severe Croup (Additional Treatment):

1. Add nebulized epinephrine 0.5 ml/kg of 1:1000 solution 1, 4
   • Provides rapid temporary relief of airway obstruction
   • Monitor for rebound airway obstruction for at least 2 hours after administration 3
   • If more than one dose of epinephrine is required, hospital admission is recommended 5

Supportive Care Measures:

1. Maintain a calm environment 1
2. Position the child comfortably 1
3. Ensure adequate hydration 1, 5
4. Provide supplemental oxygen if saturation is <92% 1
5. Monitor respiratory rate, work of breathing, and oxygen saturation 1

Important Considerations

• Avoid over-the-counter cough medications as they provide no benefit and may cause harm 1
• Cool mist humidification has limited evidence for benefit but is commonly recommended 1, 5
• Antibiotics have no proven effect on uncomplicated viral croup 5
• Antihistamines and decongestants are not effective for croup management 5

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 1

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 1

Differential Diagnosis

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 1, 2