What is the initial management for a child presenting with croup in an office setting?

Office Management of Croup in Children

For a child presenting with croup in an office setting, administer oral corticosteroids regardless of severity, with nebulized epinephrine reserved for moderate to severe cases, and consider hospital admission only after three doses of racemic epinephrine are needed. 1

Initial Assessment

• Recognize croup by its characteristic presentation of sudden onset barking cough, stridor, hoarse voice, and respiratory distress, typically without fever or other respiratory symptoms such as antecedent cough or congestion 1, 2
• Assess for signs of respiratory distress: stridor, accessory muscle use, tracheal tug, sternal/subcostal/intercostal recession 3
• An agitated, restless, or obviously distressed child may indicate significant airway obstruction 3
• Radiographic studies are generally unnecessary and should be avoided unless there is concern for an alternative diagnosis 1, 2

Treatment Algorithm

For All Cases of Croup:

• Administer oral corticosteroids regardless of severity 1, 2
  • Dexamethasone 0.6 mg/kg orally is the preferred medication 4, 5
  • Onset of action is approximately 6 hours after administration 4

For Moderate to Severe Cases (stridor at rest or respiratory distress):

• Administer nebulized epinephrine 0.5 ml/kg of 1:1000 solution 1, 4
• The effect of nebulized epinephrine is short-lived, lasting approximately 1-2 hours 1
• Provide oxygen therapy to maintain oxygen saturation ≥94% 1
• Monitor the patient for at least 2 hours after the last dose of nebulized epinephrine to assess for rebound symptoms 1, 4

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 can reduce hospitalization rates by 37% without increasing revisits or readmissions 1, 6
• If only 1-2 doses of racemic epinephrine are needed, consider monitoring in the office or emergency department for 2 hours after the last dose before discharge 6, 1

Important Considerations and Pitfalls

• 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, 3
• Consider bacterial tracheitis in patients who fail to respond to standard croup treatment 3
• Foreign body aspiration is an important differential diagnosis that should be considered 1
• Avoid blind finger sweeps in cases of suspected foreign body aspiration, as this may push objects further into the pharynx 1
• Ensure emergency equipment is readily available, including appropriate facemasks, airway adjuncts, and equipment for airway management 3
• Antihistamines, decongestants, and antibiotics have no proven effect on uncomplicated viral croup 7

Home Care Instructions

• Provide adequate hydration 7
• Consider humidification, though recent studies suggest limited benefit 5, 8
• Provide fever control as needed 7
• Educate parents on warning signs that should prompt return for care: increased work of breathing, inability to drink fluids, or worsening symptoms 1
• Implement respiratory hygiene/cough etiquette measures to prevent transmission to others 6

By following this evidence-based approach to managing croup in the office setting, you can effectively treat most children without the need for hospitalization while ensuring appropriate escalation of care when necessary.