What are the clinical presentation and treatment options for croup (respiratory condition) in a pediatric patient?

From the Guidelines

Croup is a common respiratory illness in children characterized by a barking cough, hoarseness, and inspiratory stridor due to inflammation and narrowing of the subglottic airway, and the most effective treatment approach is based on the severity of the condition, with a focus on reducing morbidity, mortality, and improving quality of life. The clinical presentation typically includes a preceding upper respiratory infection with low-grade fever, followed by the development of the characteristic barking or "seal-like" cough, particularly at night. Stridor may worsen with agitation and crying.

Clinical Presentation

• Preceding upper respiratory infection with low-grade fever
• Characteristic barking or "seal-like" cough, particularly at night
• Stridor that may worsen with agitation and crying Treatment depends on severity, with mild cases managed at home with humidity (cool mist) and upright positioning.

Treatment Approach

• Mild cases: home management with humidity and upright positioning
• Moderate to severe cases: a single dose of oral dexamethasone (0.6 mg/kg, maximum 16 mg) is the cornerstone of treatment, reducing inflammation and preventing return visits, as supported by recent studies 1
• Severe cases with respiratory distress: nebulized epinephrine (racemic epinephrine 2.25% 0.5 mL in 3 mL saline or L-epinephrine 1:1000 5 mL) provides temporary relief through mucosal vasoconstriction, but requires observation for rebound symptoms for 2-3 hours after administration, as noted in guidelines 1 Hospitalization is indicated for children with persistent stridor at rest, significant respiratory distress, hypoxemia, or those requiring multiple epinephrine treatments, and a clinical guideline limiting hospital admission until 3 doses of racemic epinephrine are needed can lead to a reduced rate of hospital admission without significant increase in revisits or readmissions, as demonstrated in a recent study 1. Antibiotics are not indicated as croup is typically viral in etiology, most commonly caused by parainfluenza virus. Parents should be counseled that symptoms often worsen at night and may last 3-7 days, with instructions to seek immediate care if the child develops increased work of breathing, lethargy, or cyanosis.

Key Considerations

• Antibiotics are not indicated for viral croup
• Parents should be counseled on the potential worsening of symptoms at night and the duration of the illness
• Immediate care should be sought if the child develops increased work of breathing, lethargy, or cyanosis, highlighting the importance of close monitoring and timely intervention to improve outcomes and quality of life, as emphasized in recent research 1

From the Research

Croup Clinical Presentation

• Croup is a common childhood illness characterized by barky cough, stridor, hoarseness, and respiratory distress 2
• Children with severe croup are at risk for intubation 2

Treatment for Croup

• A single dose of corticosteroids is the first-line treatment for croup, resulting in fewer return visits and hospital admissions, shorter lengths of stay in the emergency department (ED) or hospital, and less need for supplemental medication 3
• Nebulized racemic or L-epinephrine reduces severity of symptoms in moderate-to-severe croup 3, 2, 4
• Dexamethasone and nebulized epinephrine reduced the symptoms and hastened recovery, but dexamethasone was more effective by clinical evaluation at 6 and 12 hours post admission 5
• A 0.15 mg/kg dose of oral dexamethasone is as effective as larger doses 3
• Humidified air provides no demonstrable benefit in the acute setting 3

Administration of Nebulized Epinephrine

• Nebulized epinephrine is associated with clinically and statistically significant transient reduction of symptoms of croup 30 minutes post-treatment 2
• There is no significant difference in croup score between administration of nebulized epinephrine via intermittent positive pressure breathing (IPPB) versus nebulization alone at 30 minutes or two hours 2
• L-epinephrine showed significant reduction compared with racemic epinephrine after two hours 2

Discharge and Follow-up

• Children with croup treated with dexamethasone and mist, receiving one nebulized racemic epinephrine treatment, can be discharged after a four-hour period of observation if they appear clinically well to an experienced physician, and if close follow-up can be established 6