From the Guidelines
Croup in a 14-month-old should be treated with a single dose of oral dexamethasone (0.6 mg/kg, maximum 10 mg) for moderate to severe cases, as it reduces inflammation in the upper airway, according to the most recent and highest quality study available 1. The clinical presentation of croup in a 14-month-old typically includes a barking cough, hoarseness, stridor (especially when agitated), and respiratory distress that often worsens at night. Treatment begins with keeping the child calm and providing humidified air, which can be achieved by sitting in a steamy bathroom or going outside in cool night air. For mild cases, these measures may be sufficient. In severe cases with significant respiratory distress, nebulized epinephrine (racemic epinephrine 2.25% solution, 0.5 mL in 2.5 mL normal saline, or L-epinephrine 1:1000,5 mL) may be administered in an emergency setting, but this requires monitoring as rebound symptoms can occur. Some key points to consider in the treatment of croup include:
- Hospitalization is indicated for children with severe respiratory distress, hypoxemia, or those who don't respond to initial treatments.
- Croup is typically caused by parainfluenza virus and is self-limiting, with symptoms usually improving within 3-5 days, though the cough may persist longer.
- Parents should seek immediate medical attention if the child develops blue lips, severe retractions, lethargy, or difficulty breathing. The use of a clinical guideline and orderset has been shown to reduce hospital admissions for croup, with a goal of achieving a 25% reduction in admission rate and neck radiograph utilization among patients presenting to the emergency department 1. However, the primary focus should be on providing appropriate treatment for the child's symptoms, rather than solely on reducing hospital admissions. The most recent and highest quality study available 1 provides guidance on the effective treatment of croup in children, and should be prioritized in clinical decision-making.
From the Research
Croup Clinical Presentation
- Croup is a common childhood disease characterized by sudden onset of a distinctive barking cough, usually accompanied by stridor, hoarse voice, and respiratory distress resulting from upper airway obstruction 2.
- It is a manifestation of upper airway obstruction resulting from swelling of the larynx, trachea, and bronchi, leading to inspiratory stridor and a barking cough 3.
- Many patients experience low-grade fevers, but fever is not necessary for diagnosis 3.
Treatment for a 14-month-old
- In mild to moderate croup, give prednisolone 1.0 mg/kg and review in 1 hour 2.
- Randomized controlled trials have demonstrated that a single dose of oral, intramuscular, or intravenous dexamethasone improves symptoms and reduces return visits and length of hospitalization in children with croup of any severity 3.
- In patients with moderate to severe croup, the addition of nebulized epinephrine improves symptoms and reduces length of hospitalization 3.
- Nebulized epinephrine is associated with clinically and statistically significant transient reduction of symptoms of croup 30 minutes post-treatment 4.
- Patients with croup who are treated with racemic epinephrine, oral dexamethasone, and mist may be safely discharged home if the patient is assessed as ready for discharge after 3 hours of observation 5.
Airway Intervention
- The rate of inpatient racemic epinephrine and additional inpatient airway interventions among patients presenting to a tertiary children's hospital with croup is relatively low 6.
- Patients with ≥3 preadmission racemic epinephrine doses were more likely to have inpatient racemic epinephrine or additional airway interventions compared with 2 doses 6.