What is the management approach for a child presenting with croup?

Management of Croup in Children

For a child presenting with croup, administer oral corticosteroids (dexamethasone 0.6 mg/kg) to all patients regardless of severity, add nebulized epinephrine (0.5 mL/kg of 1:1000 solution) for moderate-to-severe cases with stridor at rest or respiratory distress, and observe for at least 2 hours after the last epinephrine dose before considering discharge. 1

Initial Assessment

When evaluating a child with suspected croup, focus on:

• Characteristic presentation: Sudden onset of barking "seal-like" cough, inspiratory stridor, hoarse voice, and respiratory distress 1, 2
• Age range: Most commonly affects children 6 months to 6 years 3, 4
• Severity indicators: Presence of stridor at rest, degree of respiratory distress, oxygen saturation, and level of agitation 1
• Exclude alternative diagnoses: Epiglottitis, bacterial tracheitis, foreign body aspiration, and retropharyngeal abscess must be ruled out clinically 1, 4

Avoid routine radiographic studies unless there is concern for an alternative diagnosis, as clinical assessment is sufficient for croup diagnosis 1.

Treatment Algorithm by Severity

Mild Croup (No Stridor at Rest)

• Administer oral dexamethasone 0.6 mg/kg (or equivalent oral prednisolone 1.0 mg/kg) 1, 2
• Provide supportive care with adequate hydration 3
• Educate families on managing fever and identifying deterioration 1

Moderate-to-Severe Croup (Stridor at Rest or Respiratory Distress)

• Give oral dexamethasone 0.6 mg/kg immediately 1, 4
• Administer nebulized epinephrine 0.5 mL/kg of 1:1000 solution (maximum 4 mL undiluted for severe cases) 1, 2
• The epinephrine effect is short-lived (1-2 hours), so anticipate potential rebound symptoms 1, 4
• Provide supplemental oxygen to maintain saturation ≥94% using nasal cannulae, head box, or face mask 1

Life-Threatening Croup

• Administer 4 mL of adrenaline 1:1000 undiluted via nebulizer 2
• Send immediately to hospital via ambulance 2
• Maintain oxygen saturation above 94% 1

Observation and Disposition Criteria

Monitor for at least 2 hours after the last dose of nebulized epinephrine to assess for rebound symptoms before considering discharge 1, 4.

Hospitalization Indicators:

• Three or more doses of racemic epinephrine required (this criterion alone can reduce hospitalization rates by 37% without increasing revisits) 1
• Oxygen saturation <92-93% 1
• Age <18 months 1
• Respiratory rate >70 breaths/min 1
• Persistent respiratory distress or exhaustion 5
• Inability of family to provide appropriate observation 6

Discharge Criteria:

• Stable after observation period with no rebound symptoms 1
• Oxygen saturation maintained ≥94% on room air 1
• Adequate oral intake and hydration 3
• Reliable family able to monitor and return if worsening 6

Important Management Principles

Do not use nebulized epinephrine in children who will be discharged shortly, as the risk of rebound symptoms after the 1-2 hour effect wears off is significant 1.

Avoid the following interventions as they provide no proven benefit:

• Humidified or heated air therapy (no evidence of symptom improvement) 1, 7
• Chest physiotherapy 1
• Antihistamines, decongestants, or antibiotics for uncomplicated viral croup 3

Minimize handling and agitation in ill children, as this reduces metabolic and oxygen requirements 1. Remember that agitation may indicate hypoxemia rather than anxiety 1.

Follow-Up Care

For children discharged home:

• Review by primary care provider if deteriorating or not improving after 48 hours 1
• Provide clear instructions on managing fever with antipyretics 1
• Educate on maintaining adequate hydration 1
• Teach recognition of deterioration signs requiring immediate return 1

Critical Pitfalls to Avoid

Do not perform blind finger sweeps if foreign body aspiration is suspected, as this may push objects further into the pharynx 1.

Do not rely on lateral neck radiographs for diagnosis, as clinical assessment is more accurate and radiographs are usually unnecessary 1.

Ensure correct dexamethasone dosing at 0.6 mg/kg, as lower doses have proven ineffective 4. The onset of action is approximately 6 hours, which is why nebulized epinephrine is often needed as a bridge therapy in severe cases 4.