From the Guidelines
Croup in pediatric patients is primarily managed with supportive care, dexamethasone, and nebulized epinephrine, with a focus on reducing hospital admissions and improving quality of life. The etiologies of croup are mainly viral infections, including parainfluenza viruses, respiratory syncytial virus, human metapneumovirus, influenza, and adenovirus 1. The diagnosis is clinical, based on the characteristic "barking" cough, inspiratory stridor, hoarseness, and respiratory distress in children typically aged 6 months to 3 years.
Workup and Treatment
For mild croup, supportive care with cool mist and hydration is sufficient. For moderate to severe croup, dexamethasone 0.6 mg/kg (maximum 10 mg) as a single oral, IM, or IV dose is the mainstay of treatment, reducing inflammation and improving symptoms within hours 1. For severe cases with significant respiratory distress, nebulized epinephrine provides temporary relief through mucosal vasoconstriction. Children receiving epinephrine should be observed for at least 2-3 hours for rebound symptoms. Supplemental oxygen should be provided for hypoxemia.
Hospitalization and Management
Hospitalization is indicated for children with severe symptoms, hypoxemia, dehydration, or those who require multiple epinephrine treatments. The viral etiology means antibiotics are not indicated unless bacterial superinfection is suspected. Most cases resolve within 3-7 days with appropriate management. Recent studies have shown that implementing clinical guidelines and ordersets can reduce hospital admissions for croup by up to 37% 1, highlighting the importance of evidence-based management in improving outcomes and quality of life for pediatric patients with croup.
Key Considerations
- Laboratory tests and imaging are generally unnecessary, though anteroposterior neck radiographs may show the classic "steeple sign" if diagnosis is uncertain.
- The use of a clinical guideline and orderset can help reduce hospital admissions and improve management of croup in pediatric patients 1.
- The focus of management should be on reducing morbidity, mortality, and improving quality of life, with a emphasis on supportive care, dexamethasone, and nebulized epinephrine as needed.
From the Research
Etiologies of Croup
- Croup is characterized by the abrupt onset of a barking cough, inspiratory stridor, hoarseness, and respiratory distress due to upper airway obstruction 2
- It is usually caused by parainfluenza virus, with 75% of infections attributed to this virus 2
- Croup affects about 3% of children per year, usually between the ages of 6 months and 3 years 2, 3
Workup of Croup
- The assessment of airway, breathing, and circulation is paramount in treating croup, with a focus on airway 4
- Laboratory studies are seldom needed for diagnosis of croup, and viral cultures and rapid antigen testing have minimal impact on management 3
- Radiography and laryngoscopy should be reserved for patients in whom alternative diagnoses are suspected 3
Treatment of Croup
- Corticosteroids, such as dexamethasone, are the mainstay of treatment for croup, and can decrease the intensity of symptoms regardless of severity 2, 5, 3, 6
- A single dose of orally administered dexamethasone (0.15-0.6 mg/kg) is effective in treating croup symptoms 5, 6
- Nebulized epinephrine can be added in cases of moderate to severe croup to improve symptoms and reduce length of hospitalization 5, 3
- Heliox can potentially reduce the work of breathing related to upper airway obstruction, but exposure to cold air or administration of cool mist are not supported by published evidence 5