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

First-Line Treatment for Croup

Oral corticosteroids should be administered immediately to all children with croup, regardless of severity, with dexamethasone 0.15-0.6 mg/kg (maximum 10-12 mg) as a single oral dose being the preferred first-line treatment. 1, 2

Treatment Algorithm

All Cases of Croup (Mild, Moderate, and Severe)

• Administer oral dexamethasone immediately as the cornerstone of treatment, with a dosing range of 0.15-0.6 mg/kg (maximum 10-12 mg) given as a single dose 1, 2, 3
• Prednisolone 1-2 mg/kg (maximum 40 mg) can be used as an alternative if dexamethasone is unavailable 1
• This single intervention reduces hospital admissions, emergency department revisits, and disease severity across all levels of croup 3, 4, 5

Mild Croup Only

• Oral dexamethasone alone is sufficient for children with mild symptoms (no stridor at rest, minimal respiratory distress) 2
• Observation at home with clear return precautions is appropriate after steroid administration 2

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

• Add nebulized epinephrine (0.5 ml/kg of 1:1000 solution, maximum 5 ml) to the corticosteroid regimen 1, 2, 3
• The effect of nebulized epinephrine is short-lived, lasting only 1-2 hours, which is why corticosteroids remain the primary treatment 1
• Monitor for at least 2 hours after the last dose of nebulized epinephrine to assess for rebound symptoms before considering discharge 1, 2

Hospitalization Criteria

Recent evidence has shifted the threshold for admission, improving resource utilization without compromising safety:

• Consider admission only after 3 doses of racemic epinephrine are required, not the traditional 2 doses 1, 2
• This updated approach reduces hospitalization rates by 37% without increasing revisits or readmissions 6, 1, 2
• Other admission criteria include oxygen saturation <92%, age <18 months, respiratory rate >70 breaths/min, or persistent difficulty breathing 2

Critical Clinical Pitfalls to Avoid

• Never discharge a child shortly after nebulized epinephrine without completing the 2-hour observation period, as rebound symptoms are common 1, 2
• Do not withhold corticosteroids in mild cases thinking they are unnecessary—evidence supports their use in all severities to prevent progression 1, 2, 5
• Avoid using nebulized epinephrine in outpatient settings where adequate observation cannot be ensured due to rebound risk 1, 2
• Do not order routine radiographs unless concerned about alternative diagnoses like foreign body aspiration or bacterial tracheitis, as they add no value to typical croup management 1, 2

Supportive Care

• Administer oxygen to maintain saturation ≥94% using nasal cannula, head box, or face mask as needed 1, 2
• Antipyretics can be used for comfort and may help with coughing 1, 2
• Minimal handling reduces metabolic and oxygen requirements in ill children 1, 2

Evidence Quality Note

The strength of evidence for corticosteroids in croup is robust, with multiple high-quality studies demonstrating benefit across all severity levels 3, 4, 5. The recent shift to requiring 3 doses of epinephrine before admission is supported by a 2022 quality improvement study showing sustained reduction in admissions without safety concerns 6, 1, 2.

Discharge Instructions

• Ensure parents can recognize worsening symptoms (increased work of breathing, inability to drink, lethargy) and know to return immediately 2
• Arrange follow-up with a general practitioner if symptoms are not improving or are worsening after 48 hours 1, 2
• Provide clear guidance that humidified or cold air lacks evidence of benefit and should not be relied upon 1