What medications and treatments should be sent home with a baby diagnosed with croup?

Management of Croup in Infants

For a baby diagnosed with croup, you should send them home with oral dexamethasone at a dose of 0.15-0.6 mg/kg as a single dose, which has been proven to reduce symptoms, prevent return visits, and improve quality of life. 1, 2

First-Line Treatment

• Oral dexamethasone is the mainstay of treatment for croup and should be prescribed at a dose of 0.15-0.6 mg/kg as a single dose 1, 2
• Lower doses (0.15 mg/kg) appear to be as effective as higher doses (0.6 mg/kg) while minimizing potential side effects 3
• Oral administration is preferred over intramuscular injection for patient comfort and compliance 4
• Benefits of dexamethasone can be seen as early as 30 minutes after administration, much earlier than the previously thought 4-6 hours 3

Alternative Treatments

• If the child cannot tolerate oral dexamethasone, nebulized budesonide 2 mg can be given as an alternative 1, 2
• For moderate to severe croup (with increased work of breathing), consider adding nebulized epinephrine (racemic epinephrine 0.5 ml/kg of 1:1000 solution, maximum 5 mL) for immediate but temporary relief 5
• Note that after nebulized epinephrine administration, patients should be observed for at least 2 hours to monitor for rebound symptoms 6

Severity Assessment

• Mild croup: Barking cough, hoarse voice, stridor only when agitated, no respiratory distress at rest 2
• Moderate-severe croup: Barking cough, stridor at rest, increased work of breathing with retractions 2
• Life-threatening signs: Cyanosis, decreased level of consciousness, fatigue/exhaustion, poor respiratory effort 5

Home Care Instructions

• Maintain adequate hydration 6
• Avoid exposing the child to irritants such as cigarette smoke 4
• Return to the emergency department if the child develops:
  • Increased work of breathing 5
  • Inability to drink fluids 6
  • Worsening stridor at rest 2
  • Fatigue or decreased responsiveness 5

Important Considerations

• A single dose of dexamethasone is usually sufficient; additional doses are rarely needed 1
• The risk of adverse effects from a single dose of dexamethasone is minimal 1
• Humidified air/cool mist therapy has not been proven effective in controlled studies and is no longer recommended as a primary treatment 4
• Over-the-counter cough medications should not be prescribed as they have little benefit and potential risks 5
• Antibiotics are not indicated for viral croup 5

Follow-up Recommendations

• If symptoms do not resolve within 2-4 weeks, the child should be re-evaluated for emergence of specific etiological factors 5
• Most cases of croup resolve within 3-7 days with appropriate treatment 6