What is the treatment for croup cough?

Treatment of Croup Cough

The treatment for croup cough includes oral corticosteroids for all cases regardless of severity, with nebulized epinephrine reserved for moderate to severe cases showing respiratory distress or stridor at rest. 1, 2

Diagnosis and Assessment

• Croup presents with a characteristic barking cough, stridor, hoarse voice, and respiratory distress, typically with sudden onset 1, 3
• Radiographic studies are generally unnecessary and should be avoided unless there is concern for alternative diagnoses 1
• Assess for severity by checking for stridor at rest, respiratory distress, increased work of breathing, and oxygen saturation 4

Treatment Algorithm

Mild Croup (Barky cough without stridor at rest)

• Administer oral dexamethasone 0.15-0.6 mg/kg (maximum 10-12 mg) as a single dose 1, 2
• Oral route is preferred over other administration methods 5
• Observe for at least 2-4 hours after treatment to ensure improvement 4

Moderate to Severe Croup (Stridor at rest, respiratory distress)

• Administer oral dexamethasone as above 1, 6
• Add nebulized epinephrine 0.5 ml/kg of 1:1000 solution (maximum 5 ml) 1, 4
• If racemic epinephrine is unavailable, L-epinephrine (1:1000) can be substituted at the same dosage 4
• Monitor for at least 2 hours after the last dose of nebulized epinephrine to assess for rebound symptoms 1, 4
• Provide oxygen therapy if saturation falls below 94% 4

Important Considerations

• The effect of nebulized epinephrine is short-lived, lasting only 1-2 hours, so monitoring for rebound symptoms is essential 1, 4
• Do not use nebulized epinephrine in children who are shortly to be discharged or on an outpatient basis due to risk of rebound symptoms 4
• Corticosteroids from hand-held inhalers with spacer devices have not been shown to be effective for croup 4
• Humidification therapy (cool mist) has not been proven beneficial despite its common use 7, 5
• Antihistamines, decongestants, and antibiotics have no proven effect on uncomplicated viral croup 8

Hospitalization Criteria

• Consider hospital admission when three or more doses of racemic epinephrine are required 1, 2
• Other indications for admission include persistent respiratory distress despite treatment or oxygen requirement to maintain saturation ≥94% 4
• Most cases of croup are mild, with only 1-8% requiring hospital admission 7

Follow-up

• Re-evaluate within 24 hours if symptoms persist 4
• If symptoms worsen after initial improvement, prompt reassessment is necessary to rule out alternative diagnoses such as bacterial tracheitis or foreign body aspiration 4

Differential Diagnoses to Consider

• Bacterial tracheitis - suspect when patient fails to respond to standard croup treatment 1, 2
• Foreign body aspiration - consider especially with sudden onset of symptoms 1, 7
• Epiglottitis - more severe presentation with drooling, dysphagia, and toxic appearance 7