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 at a dose of 0.15 to 0.60 mg/kg, which is recommended for all cases of croup regardless of severity. 1, 2

Assessment and Diagnosis

• Croup typically presents with a sudden onset of barking cough, stridor, and respiratory distress, often without significant fever or preceding respiratory symptoms 1
• Clinical assessment is the primary diagnostic method, with radiographic studies generally unnecessary unless there is concern for alternative diagnoses 1
• Differential diagnoses to consider include bacterial tracheitis, epiglottitis, foreign body aspiration, and peritonsillar or retropharyngeal abscess 2

Treatment Algorithm

Mild Croup

• Administer a single dose of oral dexamethasone (0.15-0.60 mg/kg) 1, 2
• Most children with mild croup can be managed at home after treatment 3
• Monitor for 2-3 hours after treatment to ensure symptoms are improving 1

Moderate to Severe Croup

• Administer oral dexamethasone as above 1, 4
• For stridor at rest or respiratory distress, add nebulized epinephrine (0.5 ml/kg of 1:1000 solution) 1, 5
• The effect of nebulized epinephrine is short-lived (1-2 hours), so observation after administration is essential 1
• Provide supplemental oxygen if oxygen saturation is ≤92% 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 6, 1
• Other indications for admission include oxygen saturation <92%, significant respiratory distress, or inability of family to provide appropriate observation 1

Important Considerations

• Humidification therapy has not been proven beneficial for croup 2
• Antihistamines, decongestants, and antibiotics have no proven effect on uncomplicated viral croup 7
• Children requiring nebulized epinephrine should be observed for at least 2 hours after the last dose to assess for rebound symptoms 1, 7
• Most episodes of croup are mild, with only 1-8% of patients requiring hospital admission 2
• Simultaneous administration of corticosteroids and epinephrine reduces the rate of intubation in patients with severe croup and impending respiratory failure 4

Follow-up Recommendations

• Families of children managed at home should be educated on recognizing signs of worsening respiratory distress 3
• Follow-up should be arranged if symptoms are not improving within 48 hours 3
• Most children will have resolution of cough within two days 2