Treatment of Croup
Administer oral dexamethasone 0.15-0.6 mg/kg (maximum 10-12 mg) as a single dose to all children with croup regardless of severity, and add nebulized epinephrine for moderate to severe cases. 1, 2
Initial Management by Severity
Mild Croup
- Give oral dexamethasone 0.15-0.6 mg/kg (maximum 10-12 mg) as a single dose 1, 3
- Observe for 2-3 hours to ensure symptoms are improving 2
- No nebulized treatments are needed for mild cases 2
- Avoid routine imaging unless concerned about alternative diagnoses like bacterial tracheitis or foreign body aspiration 1
Moderate to Severe Croup
- Administer oral dexamethasone 0.15-0.6 mg/kg (maximum 10-12 mg) PLUS nebulized epinephrine 1, 2
- Nebulized epinephrine dose: 0.5 mL/kg of 1:1000 solution (maximum 5 mL) 1, 2
- Observe for at least 2 hours after each epinephrine dose due to short-lived effect (1-2 hours) and risk of rebound symptoms 1, 2
- Provide supplemental oxygen via nasal cannula, head box, or face mask to maintain oxygen saturation >94% 1
Hospitalization Decision-Making
Consider admission after 3 doses of nebulized epinephrine rather than the traditional 2 doses—this approach reduces hospitalization rates by 37% without increasing revisits or readmissions 4, 1, 2. Recent evidence from the American Academy of Pediatrics supports this more conservative admission threshold 2.
Additional admission criteria include:
- Oxygen saturation <92% 1
- Age <18 months 1
- Respiratory rate >70 breaths/min 1
- Persistent difficulty breathing despite treatment 1
Critical Pitfalls to Avoid
Never discharge a patient within 2 hours of receiving nebulized epinephrine—the rebound phenomenon is real and dangerous 1, 2. This is the most common error in croup management.
Other key pitfalls:
- Do not withhold corticosteroids in mild cases—all severities benefit from dexamethasone 1, 2
- Do not use nebulized epinephrine in outpatient settings where adequate observation cannot be ensured 1, 2
- Avoid antibiotics—croup is viral and antibiotics provide no benefit 1
- Do not rely on humidified air or cold air therapy, which lack evidence of efficacy 1, 5
Alternative Corticosteroid Options
While oral dexamethasone is preferred, nebulized budesonide 2 mg is equally effective and may be used when oral administration is not feasible 4, 6. However, oral dexamethasone remains the preferred route due to ease of administration 7.
Discharge Criteria
Patients may be discharged when they demonstrate:
- Resolution of stridor at rest 1, 2
- Minimal or no respiratory distress 1, 2
- Adequate oral intake 1, 2
- Parents understand warning signs and when to return 1, 2
Provide clear return precautions: instruct parents to return immediately for worsening stridor, increased work of breathing, or inability to maintain hydration 1. If not improving after 48 hours, the child should be reviewed by their primary care provider 1.