What is the treatment for croup?

Treatment of Croup

The cornerstone treatment for croup 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 for moderate to severe cases. 1

Assessment and Diagnosis

• Croup presents with characteristic barking cough, stridor, hoarse voice, and potential respiratory distress
• Severity assessment using the Westley Croup Score:
  • Mild: Barking cough without stridor at rest
  • Moderate: Stridor at rest with some chest wall retractions
  • Severe: Significant stridor at rest, significant retractions, and decreased air entry 1

Treatment Algorithm

For All Croup Cases (Including Mild):

1. Corticosteroids:
   • Dexamethasone 0.15-0.60 mg/kg as a single oral dose 1, 2
   • Benefits include reduced inflammation, improved symptoms, and decreased hospital admissions 3, 1
   • Takes approximately 6 hours for full effect 4

For Moderate to Severe Croup:

1. Nebulized Epinephrine:
   • 0.5 ml/kg of 1:1000 solution 1
   • Provides rapid temporary relief of airway swelling 1, 5
   • Either racemic or L-epinephrine can be used (equally effective) 5
   • Consider admission after 3 total doses of racemic epinephrine 3
   • Observe for 2-3 hours after epinephrine administration to monitor for rebound symptoms 4, 5

Supportive Care:

• Maintain calm environment
• Position child comfortably
• Ensure adequate hydration
• Provide supplemental oxygen if saturation is <92% 1

Important Clinical Considerations

• Humidification therapy has not been proven beneficial despite traditional use 2, 6
• Over-the-counter cough medications should not be used as they provide no benefit and may cause harm 1
• Most croup cases are mild with only 1-8% requiring hospital admission 2
• The "3 is the new 2" approach suggests considering admission after 3 doses of racemic epinephrine rather than the traditional 2 doses 3

Discharge Criteria

Patients can be safely discharged when:

• Significant symptom improvement occurs
• 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

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

Common Pitfalls to Avoid

1. Underdosing corticosteroids: Lower steroid dosages have proven ineffective in treating croup 4
2. Automatic admission after epinephrine: Patients can be safely discharged after a 3-hour observation period if symptoms improve 5
3. Failure to consider differential diagnoses: Always consider epiglottitis, foreign body aspiration, bacterial tracheitis, retropharyngeal abscess, and other causes of stridor 1, 2
4. Overreliance on humidification: Evidence for cool mist humidification benefit is limited 1, 6

Quality improvement initiatives have shown that implementing evidence-based clinical guidelines for croup can significantly decrease hospital admissions (by up to 72%) without increasing return visits 3.