What is the treatment for croup in pediatric patients?

Treatment of Croup in Pediatric Patients

Oral corticosteroids are recommended as first-line treatment for all cases of croup regardless of severity, with nebulized epinephrine reserved for moderate to severe cases. 1, 2, 3

Assessment and Diagnosis

• Croup typically presents with a barking cough, stridor, hoarse voice, and respiratory distress, often starting like an upper respiratory tract infection 4
• Parainfluenza virus (types 1-3) is the most common cause of croup 4
• Radiographic studies are generally unnecessary and should be avoided unless there is concern for an alternative diagnosis 2
• Important differential diagnoses include bacterial tracheitis, epiglottitis, foreign body aspiration, peritonsillar abscess, retropharyngeal abscess, and angioedema 4

Treatment Algorithm Based on Severity

For All Cases of Croup:

• Administer oral dexamethasone 0.15-0.6 mg/kg (maximum 10-12 mg) as a single dose 1, 3, 5
• Lower doses (0.15 mg/kg) have been shown to be as effective as higher doses (0.6 mg/kg) for moderate to severe croup 5

For Mild Croup:

• Oral dexamethasone alone is sufficient 1, 2
• Observe for 2-3 hours to ensure symptoms are improving 1
• No need for nebulized treatments 1

For Moderate to Severe Croup (stridor at rest or respiratory distress):

• Add 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
• Observe for at least 2 hours after the last dose of nebulized epinephrine to assess for symptom rebound 1, 2
• Consider hospital admission if three or more doses of nebulized epinephrine are required 1, 2

Hospitalization Criteria

• Need for ≥3 doses of nebulized epinephrine 1, 2
• Oxygen saturation <92% 2
• Age <18 months 2
• Respiratory rate >70 breaths/min 2
• Persistent difficulty in breathing 2

Important Clinical Considerations

• Humidification therapy (mist/humidified air) has not been proven beneficial and is not recommended 4, 6
• 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
• Administer oxygen via nasal cannulae, head box, or face mask to maintain oxygen saturation above 94% 2
• Antipyretics can be used to keep the child comfortable 2
• Minimal handling may reduce metabolic and oxygen requirements in ill children 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
• If discharged home, the child should be reviewed by a general practitioner if deteriorating or not improving after 48 hours 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
• Using antibiotics routinely, as croup is typically viral in etiology 7, 8
• Relying on cold air or humidified air treatments, which lack evidence of benefit 2, 6