Weight-Based Oral Steroid Dosing for Croup
For children with croup, a single dose of oral dexamethasone at 0.15-0.6 mg/kg (maximum 10-12 mg) is the recommended weight-based steroid dosing, with 0.6 mg/kg being the most commonly used dose for moderate to severe cases and 0.15 mg/kg being effective for mild cases. 1, 2, 3
Steroid Selection and Dosing
Dexamethasone
- First-line treatment: Dexamethasone is the preferred corticosteroid for croup
- Dosing range: 0.15-0.6 mg/kg orally (maximum 10-12 mg)
- Dosing by severity:
- Administration: Single dose is typically sufficient
- Route: Oral administration is preferred due to ease of use and similar efficacy to intramuscular route 4
Alternative Steroids
- Prednisolone: Can be used at 1 mg/kg but is less effective than dexamethasone 5
- Budesonide: Nebulized budesonide 2 mg can be used as an alternative but is generally not preferred over oral dexamethasone 6
Clinical Considerations
Efficacy Evidence
- Research has demonstrated that a single dose of dexamethasone 0.15 mg/kg is equally effective as 0.6 mg/kg for treating moderate to severe croup, with both doses significantly reducing croup scores within one hour of administration 3
- Lower doses (0.15 mg/kg) may be appropriate for mild disease, while higher doses (0.6 mg/kg) are traditionally used for moderate to severe cases 2
Route of Administration
- Oral administration is preferred and equally effective as intramuscular injection for outpatient management 4
- Intramuscular dexamethasone should be reserved for:
- Children who are vomiting
- Children in severe respiratory distress who cannot tolerate oral medication 2
Important Clinical Pearls
- A single dose is typically sufficient for most cases of croup
- Corticosteroid use reduces hospitalizations, length of illness, and need for subsequent treatments 2
- Steroid-induced complications in croup treatment are rare 2
- Evaluate response to treatment within 2-4 hours
- If symptoms persist or worsen despite steroid treatment, consider additional interventions such as nebulized epinephrine (0.5 ml/kg of 1:1000 solution) 1
Caveats and Pitfalls
- Do not use over-the-counter cough medications as they provide no benefit and may cause harm 1
- Prednisolone, while available in liquid form, is less effective than dexamethasone with higher rates of symptom recurrence and medical re-presentation (29% vs 7%) 5
- Always consider other causes of stridor that may mimic croup, including epiglottitis, foreign body aspiration, and bacterial tracheitis 1
- Monitor for signs of deterioration including increased work of breathing, lethargy, or cyanosis 1
By following these weight-based dosing recommendations for oral steroids in croup, clinicians can effectively reduce symptoms, decrease hospitalizations, and improve outcomes for children with this common respiratory condition.