Is a dexamethasone injection indicated for a 4-year-old child with croup?

Dexamethasone for Croup in a 4-Year-Old

Yes, you should give dexamethasone to a 4-year-old with croup—it is the standard of care and provides consistent clinical benefit regardless of severity. The recommended dose is 0.6 mg/kg (maximum 16 mg) administered as a single dose, which can be given orally, intramuscularly, or intravenously 1.

Route of Administration

• Oral administration is preferred when the child can tolerate it, as it is equally effective as intramuscular injection and avoids the pain of injection 2, 3.
• Intramuscular injection is appropriate if the child cannot take oral medication or has severe respiratory distress 1.
• All three routes (oral, IM, IV) are equally effective for croup treatment 2.

Dosing Specifics

• Standard dose: 0.6 mg/kg (maximum 16 mg) as a single dose 1.
• For a 4-year-old weighing approximately 16-18 kg, this translates to roughly 10-11 mg.
• Lower doses (0.15 mg/kg) are also effective for moderate to severe croup, showing equivalent outcomes in clinical trials 4, though the 0.6 mg/kg dose remains the guideline-recommended standard 1.

Timing and Onset of Action

• Clinical improvement begins as early as 30 minutes after oral administration 5.
• Peak effect occurs within 1-2 hours, with sustained benefit lasting 24-72 hours 1.
• The single-dose regimen does not require tapering and does not cause significant adrenal suppression 1.

Severity-Based Considerations

Mild Croup (Westley Score ≤2)

• Dexamethasone 0.6 mg/kg orally reduces return visits to medical care (7.3% vs 15.3% with placebo), accelerates symptom resolution, and reduces parental stress 6.
• Benefits are consistent even in mild cases, supporting treatment for most if not all children with croup 6.

Moderate to Severe Croup

• Add nebulized epinephrine (0.5 mL/kg of 1:1000 solution, maximum 5 mL) for significant respiratory distress 7, 1.
• Epinephrine provides immediate but short-term relief (30-60 minutes), while dexamethasone provides longer-lasting benefit 1.
• If racemic epinephrine is unavailable, L-epinephrine (1:1000) at 0.5 mL/kg up to 5 mL is an acceptable substitute 7.
• Observe for 4 hours after epinephrine administration before considering discharge 8.

Important Clinical Pitfalls

• Do not use nebulized corticosteroids from hand-held inhalers with spacers—they are ineffective for croup 2. Oral or parenteral dexamethasone is the appropriate route.
• Nebulized budesonide is equally effective as oral dexamethasone 2, but oral administration is simpler and more practical in most settings.
• Avoid delaying treatment based on severity assessment—even mild croup benefits from dexamethasone 6.
• Single-dose therapy is sufficient—do not prescribe multiple doses or tapers 1.

Discharge Criteria After Epinephrine Use

If epinephrine was administered for moderate-severe croup:

• Child must appear clinically well after 4 hours of observation 8.
• Croup score should be significantly improved (ideally ≤2) 8.
• Close follow-up must be established 8.
• No return visits for croup occurred within 24 hours in children meeting these criteria 8.