What is the first line of treatment for a child with croup?

First-Line Treatment for Croup

Oral dexamethasone is the first-line treatment for all children with croup, regardless of severity, at a dose of 0.15-0.6 mg/kg (maximum 10-12 mg) as a single dose. 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, 3
• This is sufficient for children with mild symptoms (barking cough, minimal or no stridor at rest) 1
• Treatment at this early phase reduces symptom severity and prevents emergency department visits and hospital admissions 4

Moderate to Severe Croup

• Give oral dexamethasone PLUS nebulized epinephrine for children with stridor at rest or respiratory distress 1, 2
• Nebulized epinephrine dose: 0.5 mL/kg of 1:1000 solution (maximum 5 mL) 1, 2
• The epinephrine effect is short-lived (1-2 hours), so observe for at least 2 hours after the last dose to monitor for rebound symptoms 2, 4

Alternative Corticosteroid Options

• Nebulized budesonide 2 mg is equally effective as oral dexamethasone when oral administration is not feasible 1
• Intramuscular dexamethasone 0.6 mg/kg can be used if the child cannot tolerate oral medication 4, 5

Critical Hospitalization Criteria

Admit to the hospital if the child requires:

• ≥3 doses of nebulized epinephrine (not the traditional 2 doses) 1, 2
• Oxygen saturation <92% 1, 2
• Age <18 months 1
• Respiratory rate >70 breaths/min 1
• Persistent difficulty breathing 1

The American Academy of Pediatrics now supports admission after 3 doses rather than 2 doses of racemic epinephrine, which reduces hospitalization rates by 37% without increasing revisits or readmissions 6, 1, 2

Common Pitfalls to Avoid

• Never discharge a child too early after nebulized epinephrine—always observe for at least 2 hours to assess for rebound symptoms 2, 4
• Do not withhold corticosteroids in mild cases—all children with croup benefit from dexamethasone, even those with minimal symptoms 1, 3
• Avoid using nebulized epinephrine in outpatient settings where the child will be discharged shortly, due to risk of rebound airway obstruction 2, 7
• Do not use antibiotics routinely—croup is viral in etiology and antibiotics have no proven benefit 3, 7
• Avoid relying on humidified or cold air treatments—these lack evidence of benefit 2, 3
• Do not order neck radiographs routinely—diagnosis is clinical and imaging is unnecessary unless considering alternative diagnoses 1, 2

Supportive Care Measures

• Administer oxygen to maintain saturation ≥94% if hypoxic 2
• Use antipyretics for comfort and to help with coughing 2
• Ensure adequate hydration 2
• Minimize handling to reduce metabolic and oxygen requirements 2

Discharge Instructions

Discharge is appropriate when:

• Stridor at rest has resolved 2
• Minimal or no respiratory distress present 2
• Adequate oral intake achieved 2
• Parents can recognize worsening symptoms and know to return if needed 2
• Child should be reviewed by a general practitioner if deteriorating or not improving after 48 hours 2