What is the first line of treatment for a child with croup?

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

Hospitalization Criteria

The American Academy of Pediatrics now recommends admission after 3 doses of nebulized epinephrine rather than the traditional 2 doses 1, 2. This updated approach:

• Reduces hospitalization rates by 37% without increasing revisits or readmissions 6, 2
• Admission rate in patients receiving ≤2 doses dropped from 6.3% to 1.7% 6

Additional admission criteria include: 1, 2

• Oxygen saturation <92%
• Age <18 months
• Respiratory rate >70 breaths/min
• Persistent difficulty breathing

Common Pitfalls to Avoid

Do not discharge patients too early after nebulized epinephrine. The 2-hour observation period is mandatory because rebound airway obstruction can occur 1, 2, 5

Do not withhold corticosteroids in mild cases. Even children with mild croup benefit from dexamethasone, which prevents progression and reduces the need for subsequent medical attention 1, 4

Do not use nebulized epinephrine in outpatient settings where adequate observation cannot be ensured, as rebound symptoms pose significant risk 1, 2

Avoid unnecessary interventions: 1, 2

• Radiographic studies are generally unnecessary unless alternative diagnoses are suspected
• Humidified or cold air therapy lacks evidence of benefit
• Antibiotics are not indicated as croup is viral in etiology
• Chest physiotherapy is not beneficial

Alternative Corticosteroid Options

If oral administration is not feasible:

• Nebulized budesonide 2 mg is equally effective as oral dexamethasone 1, 4
• Intramuscular dexamethasone 0.6 mg/kg is an acceptable alternative 4, 5

Discharge Criteria

Children can be discharged when: 1, 2

• Stridor at rest has resolved
• Minimal or no respiratory distress present
• Adequate oral intake maintained
• Parents can recognize worsening symptoms and know to return if needed
• At least 2 hours have passed since last nebulized epinephrine dose

Provide clear return precautions: Families should seek immediate care if the child develops increased work of breathing, inability to drink, or worsening stridor 2