What is the first line of treatment for a child with croup?

First-Line Treatment for Croup in Children

The first-line treatment for a child with croup is oral corticosteroids, specifically dexamethasone, which should be administered to all children with croup regardless of severity. 1

Assessment and Diagnosis

• Croup presents with sudden onset of respiratory distress with a characteristic barking cough, stridor, and possible wheezing, typically without significant fever 1, 2
• Diagnosis is primarily clinical, based on the distinctive barking cough and associated symptoms 2
• Radiographic studies are generally unnecessary and should be avoided unless there is concern for an alternative diagnosis such as bacterial tracheitis or foreign body aspiration 1

Treatment Algorithm

Mild Croup

• Administer oral dexamethasone 0.15-0.6 mg/kg as a single dose for all cases of croup, even mild cases 1, 3
• Alternative: nebulized budesonide 2 mg for children who cannot tolerate oral medication 3
• Observe for 1-2 hours after treatment to ensure symptom improvement 4
• Discharge home with instructions for adequate hydration and monitoring for worsening symptoms 5

Moderate to Severe Croup

• Administer oral dexamethasone 0.15-0.6 mg/kg as above 1, 3
• Add nebulized epinephrine for moderate to severe cases with stridor at rest or respiratory distress 1, 2
  • Dosage: 0.5 ml/kg of 1:1000 solution nebulized 1
  • Note that the effect of nebulized epinephrine is short-lived (1-2 hours), requiring close monitoring for rebound symptoms 1
• Provide supplemental oxygen to maintain saturation ≥94% if needed 1

Hospitalization Criteria

• Consider hospital admission when three or more doses of racemic epinephrine are required 1
• Recent guidelines have shown that limiting hospital admission until 3 doses of racemic epinephrine are needed (rather than 1 or 2 doses) can reduce hospitalization rates by 37% without increasing revisits or readmissions 1, 6
• Children requiring two epinephrine treatments were traditionally hospitalized, but newer evidence suggests many can be safely discharged after observation 5, 6

Important Considerations

• 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
• Antihistamines, decongestants, and antibiotics have no proven effect on uncomplicated viral croup and should be avoided 5
• Despite traditional recommendations, there is limited evidence supporting the use of cool mist or exposure to cold air 3
• Always consider alternative diagnoses such as bacterial tracheitis or foreign body aspiration in children who fail to respond to standard therapy 1

Follow-up and Monitoring

• Families of children managed at home should be instructed to return if symptoms worsen or fail to improve within 24-48 hours 7
• Most children with croup will show significant improvement within 24 hours of corticosteroid administration 7