What is the first line treatment for croup?

First-Line Treatment for Croup

Oral dexamethasone (0.15-0.6 mg/kg, maximum 10-12 mg) as a single dose is the first-line treatment for all cases of croup, regardless of severity. 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
• Observe for 2-3 hours to ensure symptoms are improving 2
• No nebulized treatments are needed for mild cases 2

Moderate to Severe Croup

• Give oral dexamethasone first (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) for stridor at rest or respiratory distress 1, 2, 3
• The effect of nebulized epinephrine is short-lived (1-2 hours), requiring close monitoring 2, 3
• Observe for at least 2 hours after the last dose of nebulized epinephrine to assess for rebound symptoms 2, 3

Alternative Corticosteroid Route

• Nebulized budesonide 2 mg is equally effective as oral dexamethasone when oral administration is not feasible 1

Critical Clinical Considerations

Oxygen Therapy

• Administer oxygen via nasal cannulae, head box, or face mask to maintain oxygen saturation above 94% 1, 3
• Oxygen saturation <92% is a criterion for hospital admission 1, 3

Hospitalization Criteria

• Need for ≥3 doses of nebulized epinephrine (this reduces hospitalization rates by 37% without increasing revisits or readmissions compared to the traditional 2-dose threshold) 1, 2, 3
• Oxygen saturation <92% 1, 3
• Age <18 months 1, 3
• Respiratory rate >70 breaths/min 1, 3
• Persistent difficulty in breathing 1

Common Pitfalls to Avoid

• Never use nebulized epinephrine in children who are shortly to be discharged or on an outpatient basis due to risk of rebound symptoms 1, 2, 3
• Do not discharge patients before the 2-hour observation period after nebulized epinephrine 1, 2
• Do not withhold corticosteroids in mild cases - they should be given to all patients regardless of severity 1, 2
• Avoid using antibiotics routinely as croup is typically viral in etiology 1
• Do not rely on cold air or humidified air treatments - current evidence shows no benefits from heated or humidified air for respiratory symptoms 3
• Do not use normal saline nebulization as primary treatment - evidence supports corticosteroids and epinephrine instead 2

Discharge Criteria

• Resolution of stridor at rest 1, 2
• Minimal or no respiratory distress 1, 2
• Adequate oral intake 1, 2
• Parents able to recognize worsening symptoms and return if needed 1, 2, 3
• If discharged home, the child should be reviewed by a general practitioner if deteriorating or not improving after 48 hours 1, 3