What is the recommended treatment for croup?

Recommended Treatment for Croup

Oral corticosteroids should be administered to all children with croup regardless of severity, with nebulized epinephrine reserved for moderate to severe cases. 1

First-Line Treatment

• Oral corticosteroids are the cornerstone of croup treatment for all severity levels 1, 2:

  • Dexamethasone 0.6 mg/kg orally (maximum dose 10-12 mg) as a single dose 3, 4
  • Lower doses (0.15 mg/kg) may be equally effective for moderate to severe croup 5

• 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 (maximum 5 mL) via nebulizer 3
  • If racemic epinephrine is unavailable, L-epinephrine (1:1000) can be substituted at the same dosage 3
  • Effect is short-lived (1-2 hours), requiring observation for rebound symptoms 1

Hospitalization Criteria

• Consider hospital admission when three or more doses of racemic epinephrine are required 1, 2
• Recent guidelines show limiting hospital admission until 3 doses of racemic epinephrine are needed can reduce hospitalization rates by 37% without increasing revisits 1
• Patients requiring two epinephrine treatments should be monitored closely, with many experts recommending hospitalization 6

Treatment Based on Severity

Mild Croup

• Oral dexamethasone alone (0.6 mg/kg) 1, 7
• Some evidence supports lower doses (0.15-0.3 mg/kg) for mild disease 4

Moderate to Severe Croup

• Oral dexamethasone (0.6 mg/kg) AND nebulized epinephrine (0.5 mL/kg of 1:1000 solution) 1, 3, 7
• Provide oxygen therapy to maintain saturation ≥94% 1, 2
• Monitor for at least 2 hours after the last epinephrine dose to assess for rebound symptoms 8, 1

Important Considerations

• Nebulized epinephrine should not be used in children who are shortly to be discharged due to risk of rebound symptoms 1, 2
• Radiographic studies are generally unnecessary and should be avoided unless there is concern for an alternative diagnosis 1, 2
• Antihistamines, decongestants, antibiotics, and mist/humidified air have no proven benefit in uncomplicated viral croup 6, 9
• Key differential diagnoses to consider include bacterial tracheitis and foreign body aspiration 1, 2

Home Care Instructions

• Ensure adequate hydration 6
• Control fever if present 6
• Return for medical care if respiratory distress worsens or fails to improve 7
• Parents should be educated about the potential for symptom recurrence within 24-48 hours 7