Croup Treatment Plan
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, 2
Initial Assessment
Evaluate severity immediately by assessing:
- Stridor at rest (indicates at least moderate severity) 3
- Respiratory rate and use of accessory muscles (increased work of breathing) 3
- Ability to speak/cry normally (impaired suggests moderate-severe disease) 3
- Oxygen saturation (maintain >94%) 3
- Life-threatening signs: silent chest, cyanosis, fatigue/exhaustion, poor respiratory effort 4, 3
Radiographic studies are unnecessary unless considering alternative diagnoses like bacterial tracheitis, foreign body aspiration, or retropharyngeal abscess 1, 3.
Treatment Algorithm by Severity
Mild Croup (No Stridor at Rest)
- Give oral dexamethasone 0.15-0.6 mg/kg (maximum 10-12 mg) as a single dose 1, 5
- Observe for 2-3 hours to ensure symptoms are improving 2
- No nebulized epinephrine needed 2
- Antipyretics for comfort 3
Moderate to Severe Croup (Stridor at Rest, Respiratory Distress)
- Give oral dexamethasone 0.15-0.6 mg/kg (maximum 10-12 mg) immediately 1, 6
- Add nebulized epinephrine 0.5 ml/kg of 1:1000 solution (maximum 5 ml) 4, 1, 2
- Administer oxygen via nasal cannula, head box, or face mask to maintain saturation >94% 3
- Observe for at least 2 hours after last epinephrine dose to monitor for rebound symptoms 2, 3
The effect of nebulized epinephrine is short-lived (1-2 hours), so close monitoring is essential 4, 2. Dexamethasone onset is approximately 6 hours, making epinephrine useful as a bridge until steroids take effect 7.
Alternative Corticosteroid Options
If oral administration is not feasible:
- Nebulized budesonide 2 mg is equally effective as oral dexamethasone 1, 8, 6
- Prednisolone 1-2 mg/kg (maximum 40 mg) can substitute for dexamethasone 3
Hospitalization Criteria
Admit if any of the following are present:
- ≥3 doses of nebulized epinephrine required (this threshold reduces hospitalization by 37% without increasing revisits) 1, 2, 3
- Oxygen saturation <92% 1, 3
- Age <18 months 1, 3
- Respiratory rate >70 breaths/min 1, 3
- Persistent difficulty breathing 1
The American Academy of Pediatrics now supports waiting until 3 doses of epinephrine before admission rather than the traditional 2 doses 1, 2.
Discharge Criteria
Discharge home when all of the following are met:
- Resolution of stridor at rest 1, 2
- Minimal or no respiratory distress 1, 2
- Adequate oral intake 1, 2
- Parents able to recognize worsening symptoms and know when to return 1, 2, 3
- At least 2 hours have passed since last epinephrine dose without rebound 2, 3
Instruct families to follow up with their general practitioner if symptoms worsen or fail to improve after 48 hours 3.
Critical Pitfalls to Avoid
- Never discharge within 2 hours of nebulized epinephrine due to rebound risk 4, 2, 3
- Never use nebulized epinephrine in outpatient settings where immediate return is not feasible 4, 2, 3
- Do not withhold corticosteroids in mild cases - they reduce symptoms and hospitalization even in mild disease 1, 2, 5
- Avoid humidified air or cold air therapy - no evidence supports benefit 3, 5, 9
- Do not prescribe antibiotics routinely - croup is viral (typically parainfluenza) 5
- Do not perform chest physiotherapy - it provides no benefit 3
Special Considerations
For children with recurrent croup episodes, consider asthma as a differential diagnosis, especially with nocturnal cough worsening, exercise triggers, or family history of atopy 3.
Position children under 2 years with a neutral head position and roll under shoulders to optimize airway patency 3.
Minimal handling reduces metabolic and oxygen requirements in severely ill children 3.