What is the recommended dose of dexamethasone (corticosteroid) for a child with croup?

Dexamethasone Preparation for Children with Croup

For children with croup, administer a single dose of dexamethasone at 0.15 mg/kg orally, which is as effective as higher doses while minimizing potential side effects. 1, 2, 3

Dosing and Administration

• Dexamethasone should be given at 0.15 mg/kg as a single oral dose, which has been shown to be as effective as the traditional 0.6 mg/kg dose 2, 3
• Onset of action begins as early as 30 minutes after administration, with clinical effects lasting 24-72 hours 4, 5
• The single-dose regimen does not require tapering and does not cause significant adrenal suppression 5

Administration Timing

• For optimal effect in preventing upper airway obstruction, administer dexamethasone at least 6 hours before anticipated extubation in intubated patients 6
• For non-intubated children with croup, administer dexamethasone as soon as the diagnosis is made 4

Additional Treatments

• For moderate to severe croup with significant respiratory distress, consider adding nebulized epinephrine: 0.5 mL/kg of 1:1000 solution (maximum: 5 mL) 7, 8
• If racemic epinephrine is not available, L-epinephrine (1:1000) can be substituted at the same dosage 7, 8
• Note that the effect of nebulized epinephrine is short-lived (1-2 hours), while dexamethasone provides longer-lasting relief 5, 8

Clinical Pearls

• Low-dose dexamethasone (0.15 mg/kg) has been shown to be as effective as higher doses (0.6 mg/kg) in multiple randomized controlled trials 2, 3, 1
• The 2023 Cochrane review indicates that 0.15 mg/kg may be as effective as the standard dose of 0.60 mg/kg, though more research is needed to strengthen this evidence 1
• Corticosteroids from hand-held inhalers with spacer devices have not been shown to be effective for croup and should not be used 8
• Antihistamines, decongestants, and antibiotics have no proven effect on uncomplicated viral croup 9

Monitoring and Follow-up

• Re-evaluate the child within 24 hours if symptoms persist 8
• Consider hospital admission if three or more doses of racemic epinephrine are required, if there is persistent respiratory distress despite treatment, or if oxygen is required to maintain saturation ≥94% 8
• If symptoms worsen after initial improvement, promptly reassess to rule out alternative diagnoses such as bacterial tracheitis or foreign body aspiration 8