What is the treatment for croup?

What is Croup and How to Treat It

Croup is a viral upper airway infection causing barking cough, inspiratory stridor, and hoarseness in children 6 months to 6 years old, and should be treated with oral corticosteroids in all cases regardless of severity, with nebulized epinephrine reserved for moderate to severe cases. 1, 2

Definition and Clinical Presentation

Croup is the most common cause of upper airway obstruction in young children, typically affecting those between 6 months and 6 years of age. 3, 4 The condition is characterized by:

• Barking cough (the hallmark symptom) 3, 4
• Inspiratory stridor (harsh breathing sound on inhalation) 3, 5
• Hoarseness due to laryngeal inflammation 3
• Chest-wall indrawing with respiratory distress 5
• Often preceded by upper respiratory infection symptoms with low-grade fever 6, 4

The disease is primarily caused by parainfluenza virus (types 1-3), though other viruses can be responsible. 3, 4 Most cases are mild, with symptoms typically resolving within 2 days. 4

Treatment Algorithm

All Severity Levels: Corticosteroids First

Administer oral corticosteroids to every child with croup, regardless of how mild the symptoms appear. 1, 2, 7

• Dexamethasone 0.15-0.6 mg/kg orally (maximum 10-12 mg) is the preferred treatment 2, 4
• A single dose is typically sufficient for most children 3
• If oral administration is not tolerated, use intramuscular dexamethasone or nebulized budesonide as alternatives 3
• Onset of action is approximately 6 hours, so symptoms may not improve immediately 6

Moderate to Severe Croup: Add Nebulized Epinephrine

For children with stridor at rest or significant respiratory distress, add nebulized epinephrine to corticosteroids: 1, 7, 3

• Dose: 0.5 ml/kg of 1:1000 solution (maximum 5 ml) via nebulizer 1, 7
• Effect is rapid but short-lived (1-2 hours), requiring close monitoring 1, 7
• Critical: Observe for at least 2 hours after the last dose to assess for rebound symptoms 1, 7
• Never discharge a patient shortly after epinephrine administration due to rebound risk 1, 7

Hospitalization Criteria

Consider admission only after 3 doses of racemic epinephrine are required. 1, 2, 7 This approach reduces hospitalization rates by 37% without increasing revisits or readmissions. 8, 1, 2

Additional admission considerations include: 7

• Oxygen saturation <92-94%
• Age <18 months
• Respiratory rate >70 breaths/min
• Inability of family to provide appropriate observation

What NOT to Do: Common Pitfalls

• Do not use humidified or cold air therapy - current evidence shows no benefit 7, 9
• Do not obtain routine radiographs - diagnosis is clinical; imaging is unnecessary unless considering alternative diagnoses 7
• Do not discharge patients within 2 hours of nebulized epinephrine - this is the most critical error to avoid 1, 7
• Do not withhold corticosteroids in mild cases - all severity levels benefit 1, 3
• Do not use nebulized epinephrine in outpatient settings where extended observation is not possible 1, 7

Supportive Care

• Administer supplemental oxygen to maintain saturation ≥94% if hypoxemic 7
• Minimize handling to reduce oxygen requirements 7
• Use antipyretics for comfort 7
• Ensure adequate hydration 7

Important Differential Diagnoses

Always consider alternative diagnoses if the patient fails to respond to standard treatment: 2, 7, 4

• Bacterial tracheitis (suspect if no response to croup treatment)
• Foreign body aspiration (avoid blind finger sweeps)
• Epiglottitis
• Retropharyngeal or peritonsillar abscess

Discharge Criteria

Patients can be discharged when: 1

• Stridor at rest has resolved
• Minimal or no respiratory distress
• Adequate oral intake
• At least 2 hours have passed since last epinephrine dose
• Parents can recognize worsening symptoms and know when to return

Evidence Quality Note

The 2022 Pediatrics guideline demonstrates that implementing a structured clinical pathway with clear admission criteria (3 doses of epinephrine) significantly reduced admission rates from 10.2% to 5.5% without increasing adverse outcomes. 8 This represents high-quality evidence supporting a more conservative approach to hospitalization while maintaining patient safety.