What are the treatment steps for a child with croup?

Treatment of Croup in Children

Administer oral dexamethasone 0.15-0.6 mg/kg (maximum 10-12 mg) as a single dose to ALL children with croup regardless of severity, and add nebulized epinephrine only for moderate to severe cases. 1

Initial Assessment and Severity Classification

When evaluating a child with croup, focus on these key clinical indicators to determine severity:

• Stridor at rest indicates moderate to severe disease requiring nebulized epinephrine 1, 2
• Respiratory distress (retractions, nasal flaring, increased work of breathing) 1
• Oxygen saturation <92% is a hospitalization criterion 1
• Agitation may indicate hypoxia requiring oxygen therapy 2

Avoid unnecessary radiographic studies unless concerned about alternative diagnoses like bacterial tracheitis or foreign body aspiration 1, 2

Treatment Algorithm by Severity

Mild Croup

• Give oral dexamethasone alone (0.15-0.6 mg/kg, maximum 10-12 mg) 1
• Observe for 2-3 hours to ensure symptom improvement 3
• No nebulized treatments needed 3

Moderate to Severe Croup (stridor at rest or respiratory distress)

• Give oral dexamethasone (0.15-0.6 mg/kg, maximum 10-12 mg) 1
• Add nebulized epinephrine (0.5 ml/kg of 1:1000 solution, maximum 5 ml) 1, 3
• Observe for at least 2 hours after the last epinephrine dose to monitor for rebound symptoms 3, 2
• Administer oxygen to maintain saturation ≥94% 1, 2

Alternative corticosteroid option: Nebulized budesonide 2 mg is equally effective when oral administration is not feasible 1

Hospitalization Criteria

Consider admission after 3 doses of nebulized epinephrine rather than the traditional 2 doses—this approach reduces hospitalization rates by 37% without increasing revisits 4, 1, 3

Additional admission criteria include:

• Oxygen saturation <92% 1
• Age <18 months 1
• Respiratory rate >70 breaths/min 1
• Persistent difficulty breathing 1

Critical Pitfalls to Avoid

• Never discharge patients within 2 hours of nebulized epinephrine due to risk of rebound symptoms 1, 3, 2
• Do not withhold corticosteroids in mild cases—they reduce hospital admissions and complications 1, 5
• Avoid using nebulized epinephrine in outpatient settings where immediate discharge is planned 1, 3, 2
• Do not use humidified or cold air therapy—evidence shows no benefit 2, 6
• Avoid routine antibiotics as croup is viral 1

Discharge Criteria

Children can be discharged when they meet ALL of the following:

• Resolution of stridor at rest 1
• Minimal or no respiratory distress 1
• Adequate oral intake 1
• Parents can recognize worsening symptoms and know when to return 1, 2

Instruct families to follow up with their general practitioner if symptoms worsen or fail to improve within 48 hours 2

Supportive Care

• Use antipyretics for comfort 1, 2
• Minimize handling to reduce oxygen requirements 1, 2
• Monitor oxygen saturation at least every 4 hours if on oxygen therapy 2
• Provide clear return precautions to parents 3