Treatment for Croup in an 18-Month-Old Child
All children with croup, regardless of severity, should receive a single dose of oral dexamethasone (0.15-0.6 mg/kg, maximum 10-12 mg), with nebulized epinephrine (0.5 ml/kg of 1:1000 solution, maximum 5 ml) added for moderate to severe cases presenting with stridor at rest or respiratory distress. 1, 2, 3
Initial Assessment
Evaluate the child for:
- Barking "seal-like" cough with inspiratory stridor 4, 5
- Degree of respiratory distress: Look specifically for stridor at rest, intercostal retractions, increased work of breathing, and oxygen saturation 1, 6
- Ability of family to provide appropriate observation at home 1
Radiographic studies are unnecessary unless you suspect an alternative diagnosis such as bacterial tracheitis, epiglottitis, or foreign body aspiration 1, 3
Treatment Algorithm
For Mild Croup (stridor only with agitation, no retractions):
- Oral dexamethasone 0.15-0.6 mg/kg (maximum 10-12 mg) as a single dose 1, 3, 5
- This is sufficient as monotherapy 3
- Discharge home with clear return precautions 3
For Moderate to Severe Croup (stridor at rest, retractions, respiratory distress):
- Oral dexamethasone 0.15-0.6 mg/kg (maximum 10-12 mg) PLUS 1, 3
- Nebulized epinephrine 0.5 ml/kg of 1:1000 solution (maximum 5 ml) 1, 3
- Administer oxygen to maintain saturation ≥94% via nasal cannula, head box, or face mask 1, 3
- Observe for at least 2 hours after the last epinephrine dose to assess for rebound symptoms 1, 3
The effect of nebulized epinephrine is short-lived (approximately 1-2 hours), which is why the observation period is critical 1
Hospitalization Criteria
Consider admission if the child requires ≥3 doses of nebulized epinephrine, as limiting admission until 3 doses are needed reduces hospitalization rates by 37% without increasing revisits or readmissions 1, 2
Additional admission criteria include:
- Oxygen saturation <92% 1, 3
- Age <18 months (your patient meets this criterion, making close observation particularly important) 1, 3
- Respiratory rate >70 breaths/min 1
- Persistent difficulty breathing despite treatment 1, 3
Critical Pitfalls to Avoid
- Do NOT discharge the child within 2 hours of nebulized epinephrine administration due to risk of rebound symptoms 1, 3
- Do NOT use nebulized epinephrine in outpatient settings where you plan immediate discharge 1, 3
- Do NOT rely on humidified or cold air therapy as current evidence shows no benefit 1, 4, 7
- Do NOT perform blind finger sweeps if foreign body aspiration is suspected, as this may push objects deeper 1
- Do NOT withhold corticosteroids in mild cases - all severities benefit 1, 2, 3
Discharge Instructions
The child can be discharged home if:
- No stridor at rest 3
- Minimal or no respiratory distress 3
- Adequate oral intake 3
- Reliable family able to monitor and return if worsening 1, 3
Instruct parents to return immediately for worsening stridor, increased work of breathing, inability to drink, or lethargy 1, 3. The child should be reviewed by their primary care provider if not improving after 48 hours 1, 3