What is the recommended treatment for croup?

Treatment for Croup

The recommended 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

Assessment and Diagnosis

• Croup presents with sudden onset of respiratory distress with barking cough, stridor, hoarse voice, and respiratory distress, typically without fever or other respiratory symptoms 1, 2
• Radiographic studies are generally unnecessary and should be avoided unless there is concern for an alternative diagnosis 1, 2
• Assess for signs of respiratory distress: stridor, accessory muscle use, tracheal tug, sternal/subcostal/intercostal recession 2

Treatment Algorithm

First-Line Treatment: Corticosteroids

• Administer oral corticosteroids for all cases of croup regardless of severity 1, 2
• Dexamethasone is the preferred corticosteroid at a dose of 0.6 mg/kg (maximum 10-12 mg) orally, intramuscularly, or intravenously 3, 4
• Lower doses of dexamethasone (0.15 mg/kg) may be equally effective for moderate to severe croup, offering an alternative when resources are limited 5
• Corticosteroids reduce hospitalizations, length of illness, and subsequent treatments compared to placebo 6

For Moderate to Severe Cases: Nebulized Epinephrine

• Add nebulized epinephrine for moderate to severe cases with stridor at rest or respiratory distress 1, 3
• Dosage: 0.5 ml/kg of 1:1000 solution nebulized (maximum: 5 mL) 1, 3
• If racemic epinephrine is unavailable, L-epinephrine (1:1000) can be substituted at the same dosage 3
• The effect of nebulized epinephrine is short-lived, lasting approximately 1-2 hours 1
• Nebulized epinephrine should not be used in children who are shortly to be discharged due to risk of rebound symptoms 1, 2

Oxygen Therapy

• Administer oxygen to maintain oxygen saturation ≥94% 1
• Use simple oxygen masks or tight-fitting non-rebreathing masks as needed 1

Hospitalization Criteria

• Consider hospital admission when three or more doses of racemic epinephrine are required 1, 7
• 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
• Children requiring two epinephrine treatments were traditionally hospitalized 8, but newer evidence supports observation for up to 2 hours after the second dose before deciding on admission 7

Important Considerations and Pitfalls

• Mist/humidified air provides no additional symptom improvement and does not alter the disease process 9
• Antihistamines, decongestants, and antibiotics have no proven effect on uncomplicated viral croup 8
• Consider bacterial tracheitis in patients who fail to respond to standard croup treatment 2
• Foreign body aspiration is an important differential diagnosis; blind finger sweeps should not be performed as this may push objects further into the pharynx 1, 2
• Ensure emergency equipment is readily available when managing a child with respiratory distress 2

Home Care Instructions

• Ensure adequate hydration and fever control 8
• Educate parents about the expected course of illness and when to return for care (worsening stridor, increased work of breathing, lethargy)
• Corticosteroid-induced complications in croup are rare 6