Treatment for Croup in Infants
Oral corticosteroids are recommended as first-line treatment for all cases of croup in infants, regardless of severity, with nebulized epinephrine reserved for moderate to severe cases. 1
Initial Assessment and Treatment
- For all infants with croup, administer a single dose of oral dexamethasone 0.6 mg/kg (maximum dose 12 mg) as first-line therapy 1, 2
- Lower doses of dexamethasone (0.15 mg/kg) have also shown equivalent effectiveness for moderate to severe croup 3, 4
- For moderate to severe cases with stridor at rest or respiratory distress, administer nebulized epinephrine 0.5 mL/kg of 1:1000 solution (maximum 5 mL) 1, 2
- If racemic epinephrine is not available, L-epinephrine (1:1000) can be substituted at the same dosage 2
- The effect of nebulized epinephrine is short-lived, lasting approximately 1-2 hours, so close monitoring is required 1
Hospitalization Criteria
- Consider hospital admission when three or more doses of nebulized epinephrine are required 1
- Limiting hospital admission until 3 doses of racemic epinephrine are needed can reduce hospitalization rates by 37% without increasing revisits or readmissions 1
- Oxygen therapy should be administered to maintain oxygen saturation ≥94% 1
Home Care Instructions
- Ensure adequate hydration and fever control 5
- Avoid discharging infants shortly after receiving nebulized epinephrine due to risk of rebound symptoms 1
- Antihistamines, decongestants, and antibiotics have no proven effect on uncomplicated viral croup and should not be prescribed 5
Important Considerations
- Oral administration of dexamethasone is preferred over intramuscular or nebulized routes when possible 6, 7
- Benefits of dexamethasone may begin as early as 30 minutes after administration, much earlier than the traditionally cited 4-6 hours 4
- Mist/humidified air therapy provides no additional symptom improvement and is no longer recommended 6
- Consider differential diagnoses such as bacterial tracheitis or foreign body aspiration in infants not responding to standard therapy 1
- Avoid blind finger sweeps in cases of suspected foreign body aspiration 1
- Radiographic studies are generally unnecessary and should be avoided unless there is concern for an alternative diagnosis 1
Treatment Response
- Most infants show significant improvement within 1 hour of corticosteroid administration 3
- The median time to achieving a croup score less than or equal to two (mild symptoms) is approximately 8 hours after dexamethasone administration 3
- No significant adverse reactions have been reported from dexamethasone treatment at either 0.15 mg/kg or 0.6 mg/kg dosages 3