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, regardless of disease severity. 1, 2, 3

Assessment and Diagnosis

• Croup typically presents with sudden onset of respiratory distress, barking cough, stridor, and hoarseness due to laryngeal and/or tracheal obstruction 1, 3
• Most commonly affects children between 6 months and 6 years of age 3, 4
• Usually preceded by upper respiratory symptoms like low-grade fever and coryza 3
• Diagnosis is primarily clinical, with radiographic studies generally unnecessary unless there is concern for alternative diagnoses 1, 4

Treatment Algorithm Based on Severity

Mild Croup

• Oral dexamethasone (0.15-0.60 mg/kg) for all cases, even mild ones 1, 2, 3
• Observation for 2-3 hours to ensure symptoms are improving 2
• No nebulized treatments needed for mild cases 2

Moderate to Severe Croup

• Oral dexamethasone as above PLUS nebulized epinephrine (0.5 ml/kg of 1:1000 solution, maximum 5 ml) 1, 2, 4
• The effect of nebulized epinephrine is short-lived (1-2 hours), requiring close monitoring 1, 2
• Monitor for at least 2 hours after the last dose of nebulized epinephrine to assess for symptom rebound 2, 5

Important Clinical Considerations

• Humidification therapy has not been proven beneficial for croup 3
• Antihistamines, decongestants, and antibiotics have no proven effect on uncomplicated viral croup 6
• Normal saline nebulization is not recommended as a primary treatment 2
• Consider hospital admission if three or more doses of nebulized epinephrine are required 1, 2
• Recent guidelines show that limiting hospital admission until 3 doses of racemic epinephrine are needed can reduce hospitalization rates by 37% without increasing revisits 1, 7

Common Pitfalls to Avoid

• Failing to administer corticosteroids in mild cases - all children with croup should receive dexamethasone regardless of severity 1, 2
• Discharging patients too early after nebulized epinephrine (before the 2-hour observation period) due to risk of rebound symptoms 1, 2, 5
• Using nebulized epinephrine in children who are shortly to be discharged or on an outpatient basis 1, 2
• Not providing clear return precautions to parents regarding worsening symptoms 2
• Overlooking alternative diagnoses such as bacterial tracheitis, epiglottitis, foreign body aspiration, or retropharyngeal abscess 1, 3

Discharge Criteria

• Resolution of stridor at rest
• Minimal or no respiratory distress
• Adequate oral intake
• Parents able to recognize worsening symptoms and return if needed 2