What is the treatment for a child with croup cough?

Treatment of Croup in Children

All children with croup should receive a single dose of oral dexamethasone (0.15-0.60 mg/kg), regardless of severity, with nebulized epinephrine reserved for moderate to severe cases presenting with stridor at rest or respiratory distress. 1

Initial Assessment

When evaluating a child with the characteristic barking cough of croup, confirm the clinical diagnosis by identifying:

• Inspiratory stridor 2
• Barking, seal-like cough 3
• Hoarseness due to laryngeal obstruction 4
• Often preceded by upper respiratory symptoms with low-grade fever 2

Radiographic studies should be avoided unless there is concern for alternative diagnoses such as bacterial tracheitis, epiglottitis, foreign body aspiration, peritonsillar abscess, or retropharyngeal abscess. 1, 2

Treatment Algorithm by Severity

Mild Croup (Stridor only with agitation, no retractions)

• Administer oral dexamethasone 0.15-0.60 mg/kg as a single dose 1, 5
• This reduces symptom severity, return visits, emergency department visits, and hospital admissions 4
• For children who cannot tolerate oral medication, use nebulized budesonide 2 mg or intramuscular dexamethasone 4, 5

Moderate to Severe Croup (Stridor at rest, respiratory distress, retractions)

• Give oral dexamethasone 0.15-0.60 mg/kg immediately 1, 5
• Add nebulized epinephrine 0.5 ml/kg of 1:1000 solution for rapid reversal of airway obstruction 1, 4
• The epinephrine effect is short-lived (1-2 hours), so monitor for at least 2 hours after the last dose for rebound symptoms 1, 6
• Administer oxygen to maintain saturation ≥94% using simple masks or non-rebreathing masks as needed 1
• Position children under 2 years with neutral head position and roll under shoulders to optimize airway patency 1

Hospitalization Criteria

Admit to hospital only after three doses of racemic epinephrine are required 1. This approach reduces hospitalization rates by 37% without increasing revisits or readmissions 1. Additional admission criteria include:

• Oxygen saturation <92-93% 1
• Age <18 months with significant distress 1
• Respiratory rate >70 breaths/min 1
• Unreliable family unable to monitor or return if worsening 1

Critical Pitfalls to Avoid

Do not use over-the-counter cough suppressants or cough medicines in children with croup, as they provide no benefit and may cause significant morbidity and mortality, especially in young children 7.

Do not discharge children shortly after nebulized epinephrine due to risk of rebound symptoms—observe for at least 2 hours 1, 6.

Do not perform blind finger sweeps if foreign body aspiration is suspected, as this may push objects further into the pharynx 1.

Humidified air therapy has not been proven beneficial despite historical use 2, 5.

Disposition and Follow-Up

For children discharged home:

• Provide families with information on managing fever, preventing dehydration, and identifying signs of deterioration 1
• Advise return if symptoms worsen or fail to improve within 48 hours 1
• Most croup symptoms resolve within 2 days, with only 1-8% requiring hospitalization and <3% of admitted patients requiring intubation 2

The evidence strongly supports early corticosteroid intervention at all severity levels, which represents a dramatic shift from historical management that reserved steroids for severe cases only 4, 5.