What is the treatment for croup?

Treatment of Croup

All children with croup should receive a single dose of oral dexamethasone (0.15-0.60 mg/kg, maximum 10 mg) regardless of severity, with nebulized epinephrine reserved for moderate to severe cases, and hospitalization considered only after three doses of racemic epinephrine are required. 1, 2, 3

Initial Assessment and Severity Stratification

Immediately assess for severity indicators including:

• Stridor at rest (indicates moderate to severe disease) 1
• Respiratory distress (use of accessory muscles, respiratory rate) 1
• Oxygen saturation (hypoxemia if <94%) 1
• Ability to speak/cry normally 1

Key differential diagnoses to exclude: bacterial tracheitis, foreign body aspiration, epiglottitis, and pertussis 1, 4

Treatment Algorithm by Severity

Mild Croup (No Stridor at Rest)

• Administer oral dexamethasone 0.15-0.60 mg/kg (maximum 10 mg) as a single dose 1, 3, 4
• Observe for 2-3 hours to ensure symptom improvement 2
• No nebulized treatments needed 2
• Discharge home with clear return precautions 3

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

• Give oral dexamethasone 0.15-0.60 mg/kg (maximum 10 mg) immediately 1, 3
• Add nebulized epinephrine 0.5 ml/kg of 1:1000 solution (maximum 5 ml) 1, 2, 3
• Observe for at least 2 hours after the last epinephrine dose to assess for rebound symptoms 1, 2
• Administer oxygen to maintain saturation ≥94% 1, 3

Critical timing consideration: Dexamethasone onset of action is approximately 6 hours, while nebulized epinephrine works within minutes but lasts only 1-2 hours 1, 5

Hospitalization Criteria

Admit to hospital if any of the following are present:

• Need for ≥3 doses of nebulized epinephrine 6, 1, 2, 3
• Oxygen saturation <92% 3
• Age <18 months 3
• Respiratory rate >70 breaths/min 3
• Persistent difficulty breathing despite treatment 3

Recent evidence demonstrates that waiting until 3 doses of racemic epinephrine (rather than the traditional 2 doses) reduces hospitalization rates by 37% without increasing revisits or readmissions. 6, 1, 2

Alternative Corticosteroid Options

• Prednisolone 1-2 mg/kg (maximum 40 mg) orally if dexamethasone is unavailable 1
• Nebulized budesonide 2 mg is equally effective as oral dexamethasone when oral administration is not feasible 3, 7
• Intramuscular dexamethasone 0.6 mg/kg if oral route is impossible 5, 8

Treatments NOT Recommended

Avoid the following interventions as they lack evidence of benefit:

• Humidified or cold air therapy (no proven benefit) 1, 9
• Routine antibiotics (croup is viral) 6, 3
• Chest physiotherapy 1
• Normal saline nebulization as primary treatment 2

Discharge Criteria and Follow-Up

Discharge home when:

• Resolution of stridor at rest 2, 3
• Minimal or no respiratory distress 3
• Adequate oral intake 3
• Reliable family able to monitor and return if worsening 1, 3

Provide clear instructions to:

• Return immediately if breathing difficulty worsens, child cannot speak/cry, or develops cyanosis 3
• Follow up with primary care if not improving after 48 hours 1, 3
• Maintain adequate hydration and use antipyretics for comfort 1, 8

Critical Pitfalls to Avoid

• Never discharge patients within 2 hours of nebulized epinephrine administration due to risk of rebound symptoms 1, 2, 3
• Never use nebulized epinephrine in outpatient settings where prolonged observation is not possible 1, 2
• Never withhold corticosteroids in mild cases - all severities benefit 2, 3
• Never perform blind finger sweeps if foreign body aspiration is suspected, as this may push objects deeper 1
• Never rely solely on lateral neck radiographs for diagnosis - clinical assessment is paramount 1

Special Considerations for Recurrent Croup

If child has recurrent episodes, consider:

• Asthma as differential diagnosis (especially if cough worsens at night, triggered by exercise/irritants, or family history of atopy) 1
• Gastroesophageal reflux (if vomiting or feeding difficulties present) 1
• Potential benefit from prophylactic inhaled corticosteroids 1