What is the first line treatment for croup?

First-Line Treatment for Croup

Oral corticosteroids are recommended as 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 or dexamethasone 0.15-0.6 mg/kg) 1, 3
• No nebulized treatments are needed for mild cases 1
• Observe for 2-3 hours to ensure symptoms are improving 1

Moderate to Severe Croup

• Administer oral corticosteroids as above 1, 2, 3
• Add nebulized epinephrine (0.5 ml/kg of 1:1000 solution, maximum 5 ml) for cases with stridor at rest or respiratory distress 1, 2
• Provide oxygen therapy to maintain saturation ≥94% 2
• Monitor closely as the effect of nebulized epinephrine is short-lived (1-2 hours) 1, 2

Important Clinical Considerations

• Dexamethasone can be administered orally, which is the preferred route due to ease of administration, availability, and low cost 4
• Intramuscular dexamethasone should be reserved for patients who are vomiting or in severe respiratory distress 4
• Nebulized epinephrine should not be used in children who are shortly to be discharged or on an outpatient basis due to the risk of rebound symptoms 1, 2
• Patients should be observed for at least 2 hours after the last dose of nebulized epinephrine to assess for symptom rebound 1, 2
• Consider hospital admission when three or more doses of nebulized epinephrine are required 1, 2, 3

Evidence Strength and Consensus

• The recommendation for oral corticosteroids in all cases of croup is consistent across multiple guidelines 1, 2, 3
• Research has shown that corticosteroids reduce hospitalizations, length of illness, and need for subsequent treatments 4
• Nebulized epinephrine provides temporary relief of symptoms in moderate to severe cases but does not alter the course of the disease 5
• Humidification therapy (mist/humidified air) has not been proven beneficial and is not recommended 6

Common Pitfalls to Avoid

• Failing to administer corticosteroids in mild cases of croup 1
• Discharging patients too early after nebulized epinephrine (before the 2-hour observation period) 1, 2
• Using nebulized epinephrine in outpatient settings where monitoring for rebound symptoms is not possible 1, 2
• Unnecessary use of radiographic studies for typical croup presentations 2, 3
• Prescribing antihistamines, decongestants, or antibiotics, which have no proven effect on uncomplicated viral croup 7