What is the initial treatment for a 4-year-old with croup?

Initial Treatment for Croup in a 4-Year-Old

Administer a single dose of oral dexamethasone 0.6 mg/kg (maximum 16 mg) immediately for all cases of croup, regardless of severity, and add nebulized epinephrine only if the child has moderate-to-severe symptoms with stridor at rest or significant respiratory distress. 1, 2

Immediate Assessment

Evaluate the child's severity based on:

• Presence of stridor at rest (indicates moderate-to-severe disease) 1
• Respiratory distress signs including intercostal retractions and increased work of breathing 3
• Oxygen saturation - maintain ≥94% 1
• Agitation (may indicate hypoxemia requiring oxygen) 1

First-Line Treatment: Corticosteroids

Dexamethasone is the mainstay of treatment:

• Dose: 0.6 mg/kg (maximum 16 mg) as a single dose 1, 2
• Route: Oral administration is preferred when tolerated, as it is equally effective as intramuscular or intravenous routes and avoids injection pain 2
• Onset: Effects begin as early as 30 minutes but peak at approximately 6 hours 2, 4
• Duration: Clinical effects last 24-72 hours 2
• No tapering required - single-dose regimen does not cause significant adrenal suppression 2

Add Nebulized Epinephrine for Moderate-to-Severe Cases

Indications for nebulized epinephrine:

• Stridor at rest 1
• Significant respiratory distress or increased work of breathing 1, 3
• While waiting for dexamethasone to take effect 2

Dosing:

• 0.5 mL/kg of 1:1000 solution (maximum 5 mL) nebulized 1, 2
• Alternative: 0.5 mL of 2.25% racemic epinephrine diluted in 2.5 mL saline 5

Critical monitoring requirement:

• Observe for at least 2 hours after the last epinephrine dose to assess for rebound symptoms 1, 4
• Effects are short-lived, lasting only 1-2 hours 1
• Do not discharge shortly after epinephrine due to risk of rebound airway obstruction 1

Supportive Care

• Oxygen therapy: Administer via nasal cannula, head box, or face mask if oxygen saturation <94% 1
• Minimize handling to reduce metabolic and oxygen requirements 1
• Antipyretics for comfort and to help with coughing 1
• Adequate hydration 5

Hospitalization Criteria

Consider admission if:

• Three or more doses of racemic epinephrine are required 1
• Oxygen saturation <92% 1
• Age <18 months 1
• Respiratory rate >70 breaths/min 1
• Persistent respiratory distress 6
• Unreliable family unable to monitor appropriately 1

Recent evidence shows that limiting admission until 3 doses of epinephrine are needed reduces hospitalization rates by 37% without increasing revisits or readmissions 1.

What NOT to Do

• Avoid humidified or cold air - current evidence shows no benefit 1, 7, 3
• Do not use nebulized corticosteroids from hand-held inhalers with spacers - they are ineffective 2
• Avoid chest physiotherapy - not beneficial 1
• Do not perform radiographic studies unless concerned for alternative diagnosis (epiglottitis, foreign body, bacterial tracheitis) 1
• Avoid antibiotics - no proven effect on uncomplicated viral croup 5

Discharge Instructions

If discharged home after observation:

• Return if symptoms worsen or do not improve within 48 hours 1
• Watch for signs of deterioration including increased work of breathing, inability to drink, or lethargy 1
• Maintain hydration and fever control 1