What is the approach and management of croup?

Management of Croup

Administer oral dexamethasone 0.15-0.6 mg/kg (maximum 10-12 mg) as a single dose to all children with croup regardless of severity, and add nebulized epinephrine (0.5 ml/kg of 1:1000 solution, maximum 5 ml) only for moderate to severe cases with stridor at rest or significant respiratory distress. 1

Initial Assessment

When evaluating a child with suspected croup, focus on:

• Severity indicators: Presence of stridor at rest, degree of intercostal retractions, respiratory rate, oxygen saturation, and level of agitation 1, 2
• Hypoxemia markers: Oxygen saturation <92% requires hospitalization; maintain SpO2 >94% with supplemental oxygen 1, 2
• Age consideration: Children <18 months are at higher risk and may require admission 1
• Respiratory rate: >70 breaths/min indicates severe disease 1

Radiographic studies are unnecessary and should be avoided unless you suspect an alternative diagnosis such as bacterial tracheitis or foreign body aspiration 1, 2

Treatment Algorithm by Severity

Mild Croup (No Stridor at Rest)

• Oral dexamethasone alone is sufficient 1, 3
• Observe for 2-3 hours to ensure symptoms are improving 3
• No nebulized treatments needed 3

Moderate to Severe Croup (Stridor at Rest or Respiratory Distress)

• Oral dexamethasone PLUS nebulized epinephrine 1, 2
• Nebulized epinephrine dose: 0.5 ml/kg of 1:1000 solution, maximum 5 ml 1, 3, 2
• The effect is short-lived (1-2 hours), requiring close monitoring 3, 2
• Observe for at least 2 hours after the last epinephrine dose to assess for rebound symptoms 3, 2

Alternative Corticosteroid Option

• Nebulized budesonide 2 mg is equally effective as oral dexamethasone when oral administration is not feasible 1, 4

Hospitalization Criteria

Admit to the hospital if any of the following are present:

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

Supportive Care Measures

• Oxygen administration: Use nasal cannulae, head box, or face mask to maintain SpO2 >94% 1, 2
• Positioning: For children under 2 years, use neutral head position with a roll under the shoulders to optimize airway patency 2
• Antipyretics: Use to keep the child comfortable 1, 2
• Minimal handling: May reduce metabolic and oxygen requirements 1, 2
• Monitor oxygen saturation at least every 4 hours for patients on oxygen therapy 2

Discharge Criteria

The child can be safely discharged when:

• Resolution of stridor at rest 1, 3
• Minimal or no respiratory distress 1, 3
• Adequate oral intake 1, 3
• Parents able to recognize worsening symptoms and return if needed 1, 3, 2
• At least 2 hours have passed since the last dose of nebulized epinephrine 3, 2

Instruct families to follow up with their general practitioner if the child is deteriorating or not improving after 48 hours 1, 2

Critical Pitfalls to Avoid

• Never discharge patients before the 2-hour observation period after nebulized epinephrine due to risk of rebound symptoms 1, 3, 2
• Do not withhold corticosteroids in mild cases—they are indicated for all severities 1, 3
• Never use nebulized epinephrine in outpatient settings where immediate discharge is planned 1, 3, 2
• Avoid routine antibiotics—croup is viral in etiology 1
• Do not rely on cold air or humidified air treatments—these lack evidence of benefit 1, 2
• Do not use normal saline nebulization as primary treatment 3
• Avoid chest physiotherapy—it is not beneficial 2
• Provide clear return precautions to parents about worsening symptoms 1, 3