Treatment of Croup in Pediatric Patients
First-Line Treatment for All Severity Levels
Administer oral dexamethasone 0.15-0.6 mg/kg (maximum 10-12 mg) as a single dose to every child with croup, regardless of severity. 1, 2 This is the cornerstone of croup management and should never be withheld, even in mild cases.
- The steroid dose is critical—lower doses have proven ineffective 3
- Oral administration is preferred over intramuscular or nebulized routes 1, 4
- Onset of action occurs approximately 6 hours after administration 3
- Alternative: Nebulized budesonide 2 mg may be used when oral administration is not feasible 1
Severity-Based Treatment Algorithm
Mild Croup
- Oral dexamethasone alone is sufficient 1
- Observe for 2-3 hours to ensure symptoms are improving 5
- No nebulized treatments are needed 5
Moderate to Severe Croup (stridor at rest or respiratory distress)
- Give oral dexamethasone PLUS nebulized epinephrine 1, 6
- Nebulized epinephrine dose: 0.5 ml/kg of 1:1000 solution (maximum 5 ml) 1, 5
- Alternative dosing: 4 mL of adrenaline 1:1000 undiluted via nebulizer 7
- Critical: Observe for at least 2 hours after the last epinephrine dose to monitor for rebound symptoms 5, 6
- The effect of epinephrine is short-lived (1-2 hours) 5, 6
Hospitalization Criteria
The most recent American Academy of Pediatrics guidance recommends admission after 3 doses of nebulized epinephrine rather than the traditional 2 doses, which reduces hospitalization rates by 37% without increasing revisits or readmissions. 8, 1, 5
Additional admission criteria include:
- Oxygen saturation <92% 1, 6
- Age <18 months 1, 6
- Respiratory rate >70 breaths/min 1, 6
- Persistent difficulty breathing 1, 6
Supportive Care
- Administer oxygen via nasal cannula, head box, or face mask to maintain oxygen saturation ≥94% 6
- Use antipyretics to keep the child comfortable 6
- Minimize handling to reduce metabolic and oxygen requirements 6
- Monitor oxygen saturation at least every 4 hours for patients on oxygen therapy 6
Discharge Criteria
Children may be discharged when they meet ALL of the following:
- Resolution of stridor at rest 1, 5
- Minimal or no respiratory distress 1, 5
- Adequate oral intake 1, 5
- Parents able to recognize worsening symptoms and return if needed 1, 5
- At least 2 hours have passed since the last epinephrine dose 5, 6
Critical Pitfalls to Avoid
- Never discharge patients before the 2-hour observation period after nebulized epinephrine due to risk of rebound symptoms 1, 5, 6
- Never use nebulized epinephrine in outpatient settings or in children about to be discharged 1, 5, 6
- Do not withhold corticosteroids in mild cases—this is a common error 1, 5
- Avoid routine use of antibiotics, as croup is viral 1
- Do not rely on humidified or cold air treatments—these lack evidence of benefit 6, 4
- Radiographic studies are generally unnecessary and should be avoided unless considering alternative diagnoses 1, 6
- Do not perform chest physiotherapy—it provides no benefit 6