What is the recommended approach for outpatient management of croup?

Outpatient Management of Croup

Oral dexamethasone (0.15-0.6 mg/kg, maximum 10-12 mg) is recommended for ALL cases of croup regardless of severity, and is the cornerstone of outpatient management. 1, 2, 3

Assessment and Classification

• Croup presents with barking cough, stridor, hoarse voice, and respiratory distress, typically with sudden onset 3
• Radiographic studies are generally unnecessary and should be avoided unless there is concern for an alternative diagnosis 3
• Classify severity based on clinical presentation:
  • Mild: Occasional barking cough, no stridor at rest, minimal respiratory distress 1
  • Moderate to severe: Frequent barking cough, stridor at rest, visible respiratory distress 1, 2

Treatment Algorithm

For ALL Croup Cases (Regardless of Severity)

• Administer a single dose of oral dexamethasone 0.15-0.6 mg/kg (maximum 10-12 mg) 1, 2, 4
  • Lower doses (0.15-0.3 mg/kg) may be sufficient for mild cases 4
  • Oral administration is preferred due to ease of use, availability, and low cost 4, 5
  • Intramuscular administration should be reserved for patients who are vomiting or in severe respiratory distress 4

For Mild Croup

• After dexamethasone administration, observe for 2-3 hours to ensure symptoms are improving 1
• No nebulized treatments are needed 1
• Provide clear return precautions to parents 1

For Moderate to Severe Croup

• In addition to dexamethasone, consider referral to emergency department for nebulized epinephrine (0.5 ml/kg of 1:1000 solution, maximum 5 ml) 1, 2, 3
• Important: Nebulized epinephrine should NOT be used in outpatient settings due to risk of rebound symptoms 1, 3
• Patients receiving nebulized epinephrine should be observed for at least 2 hours after the last dose 1, 3

Discharge Criteria (After Emergency Department Care)

• 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

Common Pitfalls to Avoid

• Failing to administer corticosteroids in mild cases 1, 4
• Using humidification therapy, which has not been proven beneficial 6, 7
• Using nebulized epinephrine in outpatient settings or discharging patients too early after nebulized epinephrine (before the 2-hour observation period) 1, 3
• Not providing clear return precautions to parents 1

When to Consider Hospitalization

• If three or more doses of nebulized epinephrine are required 1, 2, 3
• Limiting hospital admission until 3 doses of racemic epinephrine are needed can reduce hospitalization rates by 37% without increasing revisits or readmissions 1, 2

Important Differential Diagnoses to Consider

• Bacterial tracheitis 3, 6
• Foreign body aspiration 3
• Epiglottitis 6
• Peritonsillar or retropharyngeal abscess 6

Expected Course

• Most children with croup have symptoms that subside quickly with resolution of cough within two days 6
• Only 1-8% of patients with croup require hospital admission and less than 3% of admitted patients require intubation 6