What is the treatment for croup?

Treatment for 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

First-Line Treatment

• Dexamethasone 0.15-0.6 mg/kg orally (maximum 10-12 mg) is the preferred corticosteroid treatment for all croup cases 3, 4
• Corticosteroids reduce symptoms, decrease hospitalization rates, and shorten illness duration 5, 4
• The benefits of corticosteroids conclusively outweigh their risks in croup management 5

Treatment Based on Severity

Mild Croup

• Oral dexamethasone alone (0.15-0.6 mg/kg) 3, 4
• Observation for 2-3 hours to ensure symptoms are improving 1
• No nebulized treatments are needed 1

Moderate to Severe Croup

• Oral dexamethasone plus nebulized epinephrine (0.5 ml/kg of 1:1000 solution, maximum 5 ml) 1, 2, 3
• The effect of nebulized epinephrine is short-lived (1-2 hours), requiring close monitoring 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

Hospitalization Criteria

• Consider hospital admission when 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 2, 3

Ineffective or Unproven Treatments

• Normal saline nebulization is not recommended as a primary treatment 1
• Current evidence does not support the use of heated or humidified air for treating croup symptoms 2
• Antihistamines, decongestants, and antibiotics have no proven effect on uncomplicated viral croup 6

Important Clinical Considerations

• 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
• Bacterial tracheitis and foreign body aspiration are important differential diagnoses to consider, especially when a patient fails to respond to standard croup treatment 2, 3
• Radiographic studies are generally unnecessary and should be avoided unless there is concern for an alternative diagnosis 2

Common Pitfalls to Avoid

• Discharging patients too early after nebulized epinephrine (before the 2-hour observation period) 1, 2
• Failing to administer corticosteroids in mild cases 1
• Not providing clear return precautions to parents 1
• Relying on lateral neck radiographs for diagnosis rather than clinical assessment 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