What is the recommended inhaled steroid treatment for a 12-month-old child with croup?

Inhaled Steroid Treatment for Croup in a 12-Month-Old Child

Nebulized budesonide at a dose of 2 mg is the recommended inhaled steroid treatment for a 12-month-old child with croup. 1, 2

First-Line Treatment Approach

• Oral corticosteroids (dexamethasone 0.15-0.6 mg/kg) remain the mainstay of treatment for croup of all severities, with nebulized epinephrine reserved for moderate to severe cases 1, 3
• For children who cannot tolerate oral dexamethasone, nebulized budesonide 2 mg can be used as an alternative treatment 1, 2
• Budesonide inhalation suspension is FDA-approved for use in children 12 months to 8 years of age, making it appropriate for a 12-month-old 4

Administration and Dosing

• Budesonide should be administered via a jet nebulizer connected to an air compressor (not with an ultrasonic nebulizer) 4
• For croup treatment, a single dose of 2 mg nebulized budesonide has been shown to be effective 2
• Studies have demonstrated that nebulized budesonide at 2 mg is as effective as oral dexamethasone 0.6 mg/kg in alleviating croup symptoms 2

Severity Assessment and Treatment Decisions

• For mild croup (stridor without intercostal retractions), a single dose of oral dexamethasone is typically sufficient 1
• For moderate-to-severe croup (stridor with increased work of breathing):
  • Add nebulized epinephrine (0.5 ml/kg of 1:1000 solution) 3, 1
  • Consider nebulized budesonide 2 mg if oral dexamethasone cannot be tolerated 1, 2

Monitoring and Follow-up

• After treatment with nebulized epinephrine, monitor the child for at least 2 hours to assess for rebound symptoms 3, 5
• Consider hospital admission if three or more doses of nebulized epinephrine are required 3, 6
• Re-evaluate within 24 hours if symptoms persist 6

Important Considerations and Cautions

• Budesonide inhalation suspension is not indicated for the relief of acute bronchospasm 4
• Always have a short-acting beta2-agonist (rescue inhaler) available to treat sudden symptoms 4
• Localized infections such as Candida albicans may occur in the mouth and throat; advise rinsing the mouth following inhalation 4
• Monitor for potential side effects including respiratory infection, rhinitis, coughing, and moniliasis 4

Treatment Alternatives

• If budesonide is not available, oral dexamethasone remains the preferred treatment 1, 5
• Contrary to common practice, exposure to cold air or administration of cool mist are not supported by evidence for treating croup 1

By following these evidence-based recommendations, you can effectively manage croup in a 12-month-old child, reducing symptoms and potentially preventing hospitalization.