What is the first line of treatment for a child with croup?

First-Line Treatment for Croup

Oral corticosteroids (specifically dexamethasone) should be administered to all children with croup regardless of severity, with a single dose of 0.15-0.6 mg/kg (maximum 10-12 mg) given as soon as the diagnosis is made. 1, 2

Treatment Algorithm

All Severity Levels

• Dexamethasone is the cornerstone of croup management and should be given to every child with croup, even those with mild disease 1, 2, 3
• The dose range is 0.15-0.6 mg/kg (maximum 10-12 mg) as a single oral dose 2, 4
• Oral administration is preferred, but intramuscular or nebulized budesonide are alternatives if the child cannot tolerate oral medication 4, 5
• This single intervention reduces emergency department visits, hospital admissions, and symptom severity 6, 4

Mild Croup

• Oral dexamethasone alone is sufficient 2
• Home care with adequate hydration and fever control 7
• Parents should be educated on recognizing deterioration and when to return 2

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

• Add nebulized epinephrine (0.5 ml/kg of 1:1000 solution, maximum 5 ml) to the corticosteroid 1, 2, 4
• The effect of epinephrine is short-lived (1-2 hours), so observe for at least 2 hours after the last dose to assess for rebound symptoms 1, 5
• Administer oxygen to maintain saturation ≥94% if needed 1, 2

Hospitalization Criteria

Consider admission when:

• Three or more doses of racemic epinephrine are required 1, 2
• Oxygen saturation <92% 1, 2
• Age <18 months 2
• Respiratory rate >70 breaths/min in infants 2
• Persistent difficulty breathing 2

Recent evidence demonstrates that waiting until 3 doses of racemic epinephrine are needed before admission (rather than 2 doses) reduces hospitalization rates by 37% without increasing revisits or adverse outcomes 8, 1

Critical Pitfalls to Avoid

• Never discharge a child within 2 hours of receiving nebulized epinephrine due to risk of rebound airway obstruction 1, 2, 5
• Do not withhold corticosteroids in mild cases - this is a common error that leads to preventable progression and return visits 2, 4
• Avoid routine antibiotics, as croup is viral in etiology 2
• Do not rely on humidified or cold air therapy - these lack evidence of benefit 1, 3
• Avoid unnecessary radiographs unless considering alternative diagnoses like bacterial tracheitis or foreign body aspiration 1, 2

Differential Diagnosis Considerations

Always consider alternative diagnoses including:

• Bacterial tracheitis 1
• Epiglottitis 3, 5
• Foreign body aspiration (never perform blind finger sweeps) 1
• Peritonsillar or retropharyngeal abscess 3