What is the management of croup in toddlers?

Management of Croup in Toddlers

The management of croup in toddlers should include oral corticosteroids for all cases regardless of severity, with nebulized epinephrine reserved for moderate to severe cases, and hospital admission only after three doses of racemic epinephrine are needed. 1

Assessment and Diagnosis

• Croup presents with a sudden onset of respiratory distress with coughing, gagging, stridor, or wheezing, typically without fever or other respiratory symptoms such as antecedent cough or congestion 1
• The barking "seal-like" cough is characteristic and often worse at night 2
• Most cases affect children between 6 months and 6 years of age, with peak incidence in the second year of life 2
• Parainfluenza virus types 1-3 are the most common causative agents 2
• Radiographic studies are generally unnecessary and should be avoided unless there is concern for an alternative diagnosis 1

Treatment Algorithm

Mild Croup

• Corticosteroids: A single dose of dexamethasone (0.15 to 0.60 mg/kg) is recommended for ALL patients with croup, including those with mild disease 2
  • Oral administration is the preferred route when possible 3
  • Dexamethasone has an onset of action of approximately 6 hours after administration 4
• Supportive care: Ensure adequate hydration and fever control 5
• Home care: Most children with mild croup can be safely managed at home after treatment 5

Moderate to Severe Croup

• Nebulized epinephrine: For moderate to severe cases with stridor at rest or respiratory distress 2
  • Dosage: 0.5 ml/kg of 1:1000 solution nebulized 1
  • The effect is short-lived (1-2 hours) 1
  • Monitor for at least 2 hours after administration for potential rebound of symptoms 4
• Oxygen therapy: Administer humidified oxygen to maintain oxygen saturation ≥94% 1
  • Use simple oxygen masks (30-50% oxygen) or tight-fitting non-rebreathing masks (higher concentrations) as needed 1
• Observation: Patients should be observed for 2 hours after the second dose of racemic epinephrine to determine if a third dose is needed 1

Hospitalization Criteria

• Hospital admission should be considered when:
  • Three or more doses of racemic epinephrine are required 1
  • Stridor persists at rest despite treatment 6
  • Evidence of exhaustion, toxicity, or respiratory distress 6
  • Inability to maintain adequate oral hydration 2
• Recent guidelines have shown that limiting hospital admission until 3 doses of racemic epinephrine are needed can reduce hospitalization rates by 37% without increasing revisits or readmissions 1

Important Considerations

• Avoid unnecessary treatments:

  • Humidification therapy has not been proven beneficial 2
  • Antihistamines, decongestants, and antibiotics have no proven effect on uncomplicated viral croup 5
  • Mist/humidified air provides no additional symptom improvement 3

• Differential diagnosis must always be considered:

  • Epiglottitis
  • Bacterial tracheitis
  • Foreign body aspiration
  • Peritonsillar or retropharyngeal abscess
  • Angioedema 2

• Monitoring: Children requiring nebulized epinephrine should be monitored for at least 2 hours after administration to watch for rebound airway obstruction 4

• Discharge planning: Most episodes of croup are mild, with only 1-8% of patients requiring hospital admission and less than 3% of admitted patients requiring intubation 2

Pitfalls to Avoid

• Do not use nebulized epinephrine in children who are shortly to be discharged or on an outpatient basis due to risk of rebound symptoms 1
• Do not perform blind finger sweeps in cases of suspected foreign body aspiration as this may push objects further into the pharynx 1
• Do not underestimate the importance of corticosteroids - ensure the correct dosage is administered, as lower steroid dosages have proven ineffective 4
• Do not rely on lateral neck radiographs for diagnosis - clinical assessment is more important and radiographs are often unnecessary 1
• Do not delay treatment with dexamethasone, as early administration can reduce complications such as the need for intubation and hospitalization 3