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 Croup 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

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

1. Mild Croup

• Administer dexamethasone 0.15-0.60 mg/kg orally as a single dose 1, 2
• Provide supportive care:
  • Maintain calm environment
  • Ensure adequate hydration
  • Control fever with appropriate antipyretics 1

2. Moderate Croup

• Administer dexamethasone 0.15-0.60 mg/kg orally as a single dose 1, 2
• Consider nebulized epinephrine (0.5 ml/kg of 1:1000 solution) if significant respiratory distress 1, 3
• Monitor for at least 2 hours after epinephrine administration for potential rebound symptoms 4
• Provide supplemental oxygen if saturation is <92% 1

3. Severe Croup

• Administer dexamethasone 0.60 mg/kg (intramuscular route may be preferred in severe cases) 4
• Administer nebulized epinephrine (0.5 ml/kg of 1:1000 solution or 4 mL of 1:1000 undiluted) 1, 5
• Provide supplemental oxygen to maintain saturation ≥92% 1
• Arrange immediate hospital transfer via ambulance 5

Important Clinical Considerations

Medication Details

• Dexamethasone onset of action is approximately 6 hours after administration 4
• Nebulized epinephrine provides rapid but temporary relief (30-120 minutes) 6
• Children requiring two or more epinephrine treatments should be hospitalized 3

What NOT to Use

• Over-the-counter cough medications provide no benefit and may cause harm 1
• Antihistamines, decongestants, and antibiotics have no proven effect on uncomplicated viral croup 3
• Recent studies show that mist/humidified air provides no additional symptom improvement 6

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

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

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

Implementation of these evidence-based guidelines for croup management can significantly decrease hospital admissions without increasing return visits, improving outcomes for children with this common respiratory condition.