First-Line Treatment for Croup
Oral dexamethasone is the first-line treatment for all children with croup, regardless of severity, at a dose of 0.15-0.6 mg/kg (maximum 10-12 mg) as a single dose. 1, 2
Treatment Algorithm by Severity
Mild Croup
- Administer oral dexamethasone alone (0.15-0.6 mg/kg, maximum 10-12 mg) as a single dose 1, 3
- This is sufficient for children with mild symptoms (barking cough, minimal or no stridor at rest) 1
- Treatment at this early phase reduces symptom severity and prevents progression, decreasing emergency department visits and hospital admissions 4
Moderate to Severe Croup
- Give oral dexamethasone PLUS nebulized epinephrine for children with stridor at rest or respiratory distress 1, 2
- Nebulized epinephrine dose: 0.5 mL/kg of 1:1000 solution (maximum 5 mL) 1, 2
- The epinephrine effect is short-lived (1-2 hours), so observe for at least 2 hours after the last dose to monitor for rebound symptoms 2, 5
Critical Clinical Considerations
Corticosteroid Administration
- Do not withhold corticosteroids in mild cases - this is a common pitfall that leads to unnecessary progression and healthcare utilization 1, 4
- Nebulized budesonide 2 mg is an alternative if oral administration is not feasible 1
- Onset of dexamethasone action is approximately 6 hours, which is why epinephrine may be needed as a bridge in severe cases 5
Nebulized Epinephrine Precautions
- Never use nebulized epinephrine in outpatient settings or shortly before discharge due to risk of rebound airway obstruction 1, 2
- The 2-hour observation period after epinephrine is mandatory before considering discharge 2
Updated Hospitalization Criteria
Consider admission only after ≥3 doses of nebulized epinephrine are required - this represents a shift from the traditional 2-dose threshold 1, 2. This updated approach:
- Reduces hospitalization rates by 37% without increasing revisits or readmissions 6, 2
- Reflects evidence that 80% of admitted patients require no further interventions after admission 6
Additional admission criteria include:
- Oxygen saturation <92% 1, 2
- Age <18 months 1, 2
- Respiratory rate >70 breaths/min 1, 2
- Persistent difficulty breathing 1
Supportive Care
- Administer oxygen to maintain saturation ≥94% if hypoxic 2
- Use antipyretics for comfort 2
- Ensure adequate hydration 2
- Avoid chest physiotherapy - it provides no benefit 2
Common Pitfalls to Avoid
- Discharging patients before the 2-hour observation period after epinephrine 1, 2
- Failing to give corticosteroids in mild cases 1
- Ordering unnecessary neck radiographs (only obtain if considering alternative diagnoses like bacterial tracheitis or foreign body) 1, 2
- Using antibiotics routinely - croup is viral 1
- Relying on humidified or cold air treatments, which lack evidence of benefit 2, 3