First-Line Treatment for Croup
Oral corticosteroids (dexamethasone) are the first-line treatment for all cases of croup, regardless of severity, with nebulized epinephrine reserved for moderate to severe cases. 1, 2
Treatment Algorithm
All Severity Levels
- Administer oral dexamethasone 0.15-0.6 mg/kg (maximum 10-12 mg) as a single dose immediately 1, 2
- This is the cornerstone of croup management and should be given to every patient with croup, even mild cases 1, 3
- Nebulized budesonide 2 mg is an equally effective alternative when oral administration is not feasible 1, 4
Mild Croup
- Oral dexamethasone alone is sufficient 1, 3
- Observe for 2-3 hours to ensure symptoms are improving 3
- No nebulized treatments are needed 3
Moderate to Severe Croup
- Add nebulized epinephrine (0.5 ml/kg of 1:1000 solution, maximum 5 ml) 1, 2, 3
- The effect is short-lived, lasting only 1-2 hours, requiring close monitoring 2, 3
- Observe for at least 2 hours after the last epinephrine dose to assess for rebound symptoms 2, 3
Hospitalization Criteria
Consider admission only after 3 doses of nebulized epinephrine are required 5, 1, 2. This updated threshold (rather than the traditional 2 doses) reduces hospitalization rates by 37% without increasing revisits or readmissions 5, 2.
Additional admission criteria include: 2
- Oxygen saturation <92%
- Age <18 months
- Respiratory rate >70 breaths/min
- Persistent difficulty breathing
Critical Pitfalls to Avoid
- Never discharge a patient within 2 hours of nebulized epinephrine administration due to risk of rebound symptoms 2, 3
- Never use nebulized epinephrine in outpatient settings where immediate return is not feasible 1, 2, 3
- Do not fail to administer corticosteroids in mild cases—this is a common error 1, 3
- Do not use humidified or cold air therapy, as current evidence shows no benefit 2, 6
- Do not use antibiotics routinely, as croup is viral in etiology 1, 7
Supportive Care
- Administer oxygen to maintain saturation ≥94% using nasal cannulae, head box, or face mask 1, 2
- Use antipyretics for comfort 1, 2
- Minimize handling to reduce metabolic and oxygen requirements 2
- Ensure adequate hydration 2
Discharge Criteria
Patients may be discharged when: 1, 3
- Stridor at rest has resolved
- Minimal or no respiratory distress present
- Adequate oral intake maintained
- Parents can recognize worsening symptoms and know to return if needed
- At least 2 hours have passed since last epinephrine dose (if given)
Instruct families to follow up with their general practitioner if the child is deteriorating or not improving after 48 hours 2