Management of Croup in Children
All children with croup should receive oral corticosteroids regardless of severity, with dexamethasone 0.15-0.6 mg/kg (maximum 10-12 mg) as a single dose being the first-line treatment, and nebulized epinephrine reserved for moderate to severe cases with stridor at rest or respiratory distress. 1, 2
Initial Assessment
When a child presents with croup, focus on:
- Barking cough, stridor, hoarse voice, and respiratory distress are the hallmark features 3
- Oxygen saturation measurement is critical—levels <92% indicate need for hospital admission 1, 2
- Respiratory rate: >70 breaths/min in infants or >50 breaths/min in older children warrants admission 1
- Work of breathing: Look for intercostal retractions, nasal flaring, and use of accessory muscles 4
- Level of agitation: May indicate hypoxia rather than anxiety 1
Radiographic studies are unnecessary and should be avoided unless considering alternative diagnoses such as bacterial tracheitis or foreign body aspiration 1, 2
Treatment Algorithm by Severity
Mild Croup (Stridor only with activity, no retractions)
- Administer oral dexamethasone 0.15-0.6 mg/kg (maximum 10-12 mg) as a single dose 1, 2
- Review in 1 hour to assess response 3
- This alone is sufficient for mild cases 2
Moderate to Severe Croup (Stridor at rest, respiratory distress, retractions)
- Give oral dexamethasone 0.15-0.6 mg/kg (maximum 10-12 mg) 1, 2
- Add nebulized epinephrine 0.5 ml/kg of 1:1000 solution (maximum 5 ml) 1, 2
- Alternative dosing: 4 mL of 1:1000 adrenaline undiluted via nebulizer 3
- Monitor for at least 2 hours after the last dose of nebulized epinephrine to assess for rebound symptoms 1
Critical pitfall: The effect of nebulized epinephrine is short-lived (1-2 hours), so never discharge a child shortly after administration without adequate observation 1, 2
Oxygen Therapy
- Administer oxygen to maintain saturation ≥94% via nasal cannulae, head box, or face mask 1, 2
- Monitor oxygen saturation at least every 4 hours for patients on oxygen therapy 1
- Minimal handling reduces metabolic and oxygen requirements in ill children 1, 2
Hospitalization Criteria
Admit to hospital if any of the following are present:
- Need for ≥3 doses of nebulized epinephrine 1, 2
- Oxygen saturation <92% 1, 2
- Age <18 months 1, 2
- Respiratory rate >70 breaths/min 1, 2
- Persistent difficulty in breathing or stridor at rest 1, 2
- Signs of dehydration 1
- Family unable to provide appropriate observation 1
Recent evidence shows that limiting hospital admission until 3 doses of racemic epinephrine are needed can reduce hospitalization rates by 37% without increasing revisits or readmissions 1
Alternative Corticosteroid Options
- Nebulized budesonide 2 mg can be given to children who cannot tolerate oral dexamethasone 4
- Oral prednisolone 1.0 mg/kg is an alternative 3
- Intramuscular dexamethasone 0.6 mg/kg if oral route not feasible 5
Discharge Planning
Children can be discharged home when:
- Resolution of stridor at rest 2
- Minimal or no respiratory distress 2
- Adequate oral intake 2
- Parents able to recognize worsening symptoms 2
Provide families with:
- Information on managing fever and preventing dehydration 1
- Clear instructions to return if deteriorating or not improving after 48 hours 1, 2
- Reassurance that the child should be reviewed by a general practitioner if symptoms worsen 1
What NOT to Do
- Do not use antibiotics routinely—croup is viral in etiology 2
- Do not rely on cold air or humidified air treatments—these lack evidence of benefit 1, 2
- Do not use nebulized epinephrine in outpatient settings where adequate observation cannot be provided due to rebound risk 1, 2
- Do not perform chest physiotherapy—it is not beneficial 1
- Do not discharge before 2-hour observation period after nebulized epinephrine 1, 2