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

First-Line Treatment for Croup in Children

Oral dexamethasone is the first-line treatment for all children with croup, regardless of severity. 1, 2

Corticosteroid Administration

• Administer oral dexamethasone 0.15-0.6 mg/kg (maximum 10-12 mg) as a single dose to all children presenting with croup, including those with mild disease 1, 3, 4
• This single dose improves symptoms, reduces return visits, and decreases hospitalization rates across all severity levels 4
• If oral administration is not feasible (due to vomiting or severe distress), nebulized budesonide 2 mg is equally effective as an alternative 1
• Intramuscular dexamethasone can also be used when oral route is not tolerated 5

Severity-Based Treatment Algorithm

Mild Croup

• Oral dexamethasone alone is sufficient for children with mild symptoms (occasional barking cough, no stridor at rest) 1
• Most children with mild croup can be managed at home after a single dose 6

Moderate to Severe Croup

• Add nebulized epinephrine (0.5 ml/kg of 1:1000 solution, maximum 5 ml) for children with stridor at rest or respiratory distress 1, 2
• The effect of nebulized epinephrine is short-lived, lasting approximately 1-2 hours 2
• Observe for at least 2 hours after the last dose of nebulized epinephrine to assess for rebound symptoms before considering discharge 2

Critical Pitfall to Avoid

Never use nebulized epinephrine in children who will be discharged shortly or on an outpatient basis due to the significant risk of rebound symptoms after the medication wears off 1, 2. This is a common and dangerous error in practice.

Updated Hospitalization Criteria

Recent evidence from the American Academy of Pediatrics supports a more conservative approach to admission:

• Consider hospitalization only after 3 doses of nebulized epinephrine are required (not the traditional 2 doses) 1, 2
• This updated threshold reduces hospitalization rates by 37% without increasing revisits or readmissions 7, 1
• Other admission criteria include: oxygen saturation <92%, age <18 months, respiratory rate >70 breaths/min, or persistent difficulty breathing 1, 2

Treatments to Avoid

• Do not use humidified or cold air therapy as current evidence shows no benefit for respiratory symptoms 2
• Radiographic studies are generally unnecessary and should be avoided unless an alternative diagnosis is suspected 1, 2
• Antibiotics have no role in uncomplicated viral croup 8

Supportive Care

• Administer oxygen to maintain saturation ≥94% if hypoxic 2
• Use antipyretics for comfort and to help with coughing 2
• Ensure adequate hydration 8
• Minimize handling to reduce metabolic and oxygen requirements 2