What is the first line treatment for croup?

First-Line Treatment for Croup

Oral corticosteroids are the first-line treatment for all cases of croup, regardless of severity. 1, 2, 3

Treatment Algorithm Based on Severity

Mild Croup

• Administer oral corticosteroids (prednisolone 1.0 mg/kg) even in mild cases 1, 2
• Observation for 2-3 hours to ensure symptoms are improving 3
• No need for nebulized treatments in mild cases 3

Moderate to Severe Croup

• Oral corticosteroids remain the foundation of treatment 1, 3
• Add nebulized epinephrine (0.5 ml/kg of 1:1000 solution, maximum 5 ml) for moderate to severe cases with stridor at rest or respiratory distress 1, 2
• The effect of nebulized epinephrine is short-lived, lasting approximately 1-2 hours, requiring close monitoring 1, 3
• Provide high-flow oxygen to maintain saturation ≥94% as needed 1, 2

Hospitalization Criteria

• Consider hospital admission when three or more doses of racemic epinephrine are required 1, 2, 3
• 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 4, 1
• Patients should be monitored for at least 2 hours after the last dose of nebulized epinephrine to assess for rebound symptoms 1, 3

Important Clinical Considerations and Pitfalls

Evidence-Based Practices

• Radiographic studies are generally unnecessary and should be avoided unless there is concern for an alternative diagnosis 1, 2
• Normal saline nebulization is not recommended as a primary treatment for croup 3
• Mist/humidified air provides no additional symptom improvement 5

Common Pitfalls to Avoid

• 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
• Failing to administer corticosteroids in mild cases is a common error 3, 6
• Discharging patients too early after nebulized epinephrine (before the 2-hour observation period) 3
• Not considering alternative diagnoses such as bacterial tracheitis, epiglottitis, or foreign body aspiration when patients fail to respond to standard treatment 2, 7

Discharge Criteria

• Resolution of stridor at rest 3
• Minimal or no respiratory distress 3
• Adequate oral intake 3
• Parents able to recognize worsening symptoms and return if needed 3, 8