What is the appropriate treatment and management plan for a child diagnosed with croup?

Management of Croup in Children

The standard treatment for croup includes 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

Clinical Presentation and Assessment

• Croup typically presents with sudden onset of barking cough, stridor, hoarseness, and respiratory distress, usually without fever or other respiratory symptoms such as antecedent cough or congestion 1, 2
• Assessment should focus on signs of respiratory distress including stridor, accessory muscle use, tracheal tug, and sternal/subcostal/intercostal recession 2
• An agitated, restless, or obviously distressed child may indicate significant airway obstruction requiring immediate intervention 2
• Radiographic studies are generally unnecessary for typical croup and should be avoided unless there is concern for an alternative diagnosis such as bacterial tracheitis or foreign body aspiration 1, 2

Treatment Algorithm

For All Croup Cases:

• Administer oral corticosteroids (prednisolone 1.0 mg/kg or dexamethasone 0.15-0.6 mg/kg) regardless of severity 1, 3
• Nebulized budesonide (2 mg) can be used as an alternative for children who cannot tolerate oral medications 3
• Ensure adequate hydration 4

For Moderate to Severe Cases (Stridor at Rest or Respiratory Distress):

• Add nebulized epinephrine (0.5 ml/kg of 1:1000 solution or 0.5 mL of 2.25% racemic epinephrine diluted in 2.5 mL saline) 1, 4
• The effect of nebulized epinephrine is short-lived, lasting approximately 1-2 hours, requiring close monitoring for symptom rebound 1, 5
• Provide oxygen therapy to maintain saturation ≥94% 1
• Observe for at least 2 hours after epinephrine administration to monitor for rebound symptoms 1

Hospitalization Criteria

• Consider hospital admission when three or more doses of racemic epinephrine are required 1, 6
• Recent guidelines have shown that limiting hospital admission until 3 doses of racemic epinephrine are needed (rather than after 1-2 doses) can reduce hospitalization rates by 37% without increasing revisits or readmissions 6, 1
• Other indications for admission include stridor at rest that persists despite treatment, evidence of exhaustion, toxicity, or significant respiratory distress 7

Important Considerations and Potential Complications

• Nebulized epinephrine should not be used in children who are shortly to be discharged or on an outpatient basis due to risk of rebound symptoms 1, 2
• Bacterial tracheitis is an important differential diagnosis that should be suspected when a patient fails to respond to standard croup treatment 2
• Foreign body aspiration should be considered in cases with atypical presentation or poor response to treatment 1
• Antihistamines, decongestants, and antibiotics have no proven effect on uncomplicated viral croup and should be avoided 4
• In rare cases, croup can be a manifestation of COVID-19 infection, so testing should be considered during pandemic periods 8

Treatment Response Monitoring

• Monitor for improvement in stridor, work of breathing, and overall respiratory status 2
• Expect significant improvement within 30 minutes after nebulized epinephrine administration 5
• Observe for at least 2 hours after the last dose of epinephrine before considering discharge 1
• Ensure emergency equipment is readily available for children with moderate to severe respiratory distress 2