Treatment of Croup
Oral corticosteroids are recommended for ALL cases of croup regardless of severity, with nebulized epinephrine reserved for moderate to severe cases. 1, 2, 3
Diagnosis and Assessment
- Croup typically presents with a barking cough, stridor, hoarse voice, and respiratory distress, often starting like an upper respiratory infection 4, 5
- Radiographic studies are generally unnecessary and should be avoided unless there is concern for an alternative diagnosis 2
- Important differential diagnoses to consider include bacterial tracheitis, epiglottitis, foreign body aspiration, peritonsillar abscess, and retropharyngeal abscess 4, 2
Treatment Algorithm Based on Severity
Mild Croup
- Administer oral dexamethasone 0.15-0.6 mg/kg (maximum 10-12 mg) for all cases 1, 3
- Observation for 2-3 hours to ensure symptoms are improving 1
- No nebulized treatments are necessary 1
Moderate to Severe Croup (stridor at rest or respiratory distress)
- Administer oral dexamethasone as above 1, 3
- Add nebulized epinephrine (0.5 ml/kg of 1:1000 solution, maximum 5 ml) 1, 2
- Monitor for at least 2 hours after the last dose of nebulized epinephrine to assess for rebound symptoms 1, 2
- Provide oxygen therapy to maintain oxygen saturation ≥94% if needed 2
Hospitalization Criteria
- Consider hospital admission when three or more doses of racemic epinephrine are required 6, 1, 2
- Recent guidelines show limiting hospital admission until 3 doses of racemic epinephrine are needed can reduce hospitalization rates by 37% without increasing revisits 6, 2
Discharge Criteria
- Resolution of stridor at rest 1
- Minimal or no respiratory distress 1
- Adequate oral intake 1
- Parents able to recognize worsening symptoms and return if needed 1
Important Clinical Considerations and Pitfalls to Avoid
- Do not use nebulized epinephrine in children who are shortly to be discharged or on an outpatient basis due to the risk of rebound symptoms 1, 2
- Always observe patients for at least 2 hours after the last dose of nebulized epinephrine 1, 2
- Do not fail to administer corticosteroids even in mild cases 1
- Humidification therapy has not been proven beneficial and is not recommended 4, 7
- Normal saline nebulization is not recommended as a primary treatment 1
- Do not perform blind finger sweeps in cases of suspected foreign body aspiration 2
- Avoid discharging patients too early after nebulized epinephrine (before the 2-hour observation period) 1
- Always provide clear return precautions to parents 1
Medication Details
- Dexamethasone can be given orally, intramuscularly, or intravenously, but oral administration is preferred 7
- The effect of nebulized epinephrine is short-lived (1-2 hours), requiring close monitoring 1, 2
- Antihistamines, decongestants, and antibiotics have no proven effect on uncomplicated viral croup 8