What is the treatment plan for croup?

Treatment Plan for Croup

The recommended treatment for croup includes oral corticosteroids for all cases regardless of severity, with nebulized epinephrine added for moderate to severe cases. 1, 2

Assessment and Classification

• Croup presents with barking cough, stridor, hoarse voice, and respiratory distress, typically without fever or other respiratory symptoms 3
• Classify severity based on clinical presentation:
  • Mild: Barking cough without stridor at rest 1
  • Moderate to severe: Stridor at rest, respiratory distress, use of accessory muscles 1, 3

First-Line Treatment

• Administer oral dexamethasone 0.15-0.6 mg/kg (maximum 10-12 mg) for ALL cases of croup, regardless of severity 1, 2, 4
• Corticosteroids reduce inflammation, decrease symptoms, and reduce complications such as need for intubation and hospitalization 5
• Oral administration is preferred, but nebulized budesonide (2 mg) can be used if oral dexamethasone is not tolerated 6

Treatment for Moderate to Severe Croup

• For moderate to severe cases, add nebulized epinephrine (0.5 ml/kg of 1:1000 solution, maximum 5 ml) 7, 1, 2
• The effect of nebulized epinephrine is short-lived (1-2 hours), requiring close monitoring 1, 8
• Patients must be observed for at least 2 hours after the last dose of nebulized epinephrine to assess for rebound symptoms 1, 8
• Nebulized epinephrine should NOT be used in children who are shortly to be discharged or on an outpatient basis due to risk of rebound symptoms 7, 1

Hospitalization Criteria

• Consider hospital admission when three or more doses of racemic epinephrine are required 1, 2
• Other criteria for admission include:
  • Oxygen saturation <92% 3
  • Age <18 months 3
  • Respiratory rate >70 breaths/min 3
  • Significant respiratory distress 3

Supportive Care

• Administer oxygen via nasal cannula, head box, or face mask to maintain oxygen saturation above 94% 3
• Minimize handling to reduce metabolic and oxygen requirements in severely ill children 3
• Current evidence does NOT support the use of humidified air or cold air for symptom relief 3, 5, 6

Discharge Criteria and Follow-up

• 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
• Provide clear return precautions to parents 1
• The child should be reviewed by a primary care provider if deteriorating or not improving after 48 hours 3

Common Pitfalls to Avoid

• Discharging patients too early after nebulized epinephrine (before the 2-hour observation period) 1
• Failing to administer corticosteroids in mild cases 1, 4
• Not providing clear return precautions to parents 1
• Using humidification therapy which has not been proven beneficial 4, 5
• Overlooking alternative diagnoses such as bacterial tracheitis, epiglottitis, or foreign body aspiration 3, 4