What is the first line of treatment for a child with croup?

First-Line Treatment for Croup in Children

Oral corticosteroids are the first-line treatment for all cases of croup, regardless of severity, with nebulized epinephrine reserved for moderate to severe cases. 1

Assessment and Diagnosis

• Croup typically presents with a sudden onset of barking cough, stridor, and respiratory distress, often preceded by upper respiratory symptoms 2
• Clinical diagnosis is preferred over radiographic studies, which should be avoided unless there is concern for alternative diagnoses 1
• Severity assessment should guide treatment decisions and disposition 3

Treatment Algorithm Based on Severity

Mild Croup

• Single dose of oral dexamethasone (0.15 to 0.60 mg/kg) is recommended for ALL cases of croup, even mild cases 1, 2
• Observation for 2-3 hours to ensure symptoms are improving 3
• No nebulized epinephrine needed for mild cases 3

Moderate to Severe Croup

• Oral dexamethasone (0.15 to 0.60 mg/kg) as the cornerstone of treatment 1, 2
• Nebulized epinephrine (0.5 ml/kg of 1:1000 solution, maximum 5 ml) for temporary symptom relief 1, 3
• Monitor for at least 2 hours after the last dose of nebulized epinephrine to assess for rebound symptoms 3
• Consider hospital admission if three or more doses of nebulized epinephrine are required 1, 3

Evidence-Based Management Pearls

• Corticosteroids reduce the severity of symptoms, rates of return visits, emergency department visits, and hospital admissions 4
• Most children respond to a single oral dose of dexamethasone 4
• For children who cannot tolerate oral medication, nebulized budesonide or intramuscular dexamethasone are reasonable alternatives 4
• Humidification therapy has not been proven beneficial 2
• Normal saline nebulization is not recommended as a primary treatment 3

Hospitalization Criteria

• Consider hospital admission when three or more doses of racemic epinephrine are required 1, 3
• Recent guidelines show that limiting hospital admission until 3 doses of racemic epinephrine are needed can reduce hospitalization rates by 37% without increasing revisits 5, 1
• Admission indicators include persistent stridor at rest, respiratory distress, dehydration, or inability of family to provide appropriate observation 3

Common Pitfalls to Avoid

• Discharging patients too early after nebulized epinephrine (before the 2-hour observation period) 3
• Failing to administer corticosteroids in mild cases 3, 4
• Using nebulized epinephrine in children who are shortly to be discharged or on an outpatient basis due to risk of rebound symptoms 1, 3
• Not providing clear return precautions to parents 3

Differential Diagnosis Considerations

• Consider bacterial tracheitis, epiglottitis, foreign body aspiration, peritonsillar abscess, retropharyngeal abscess, and angioedema 1, 2
• Avoid blind finger sweeps in cases of suspected foreign body aspiration 1