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, administered as a single dose of 0.15-0.6 mg/kg (maximum 10-12 mg). 1, 2

Treatment Algorithm by Severity

Mild Croup

• Administer oral dexamethasone alone (0.15-0.6 mg/kg, maximum 10-12 mg as a single dose) 1, 3
• This is sufficient for children with stridor only during activity or agitation, without respiratory distress at rest 4

Moderate to Severe Croup

• Give oral dexamethasone PLUS nebulized epinephrine (0.5 ml/kg of 1:1000 solution, maximum 5 ml) 1, 2
• Nebulized epinephrine is reserved for children with stridor at rest or signs of respiratory distress 5, 4
• The effect of epinephrine is short-lived (1-2 hours), requiring close monitoring 2

Alternative Corticosteroid Options

• Nebulized budesonide 2 mg can be used when oral administration is not feasible (vomiting, severe distress) 1, 5
• Intramuscular dexamethasone is an option if oral route is impossible 6

Critical Observation Period

Children receiving nebulized epinephrine must be observed for at least 2 hours after the last dose to monitor for rebound symptoms before considering discharge 2, 7

Hospitalization Criteria

Consider admission if the child requires:

• ≥3 doses of nebulized epinephrine (recent evidence supports waiting until 3 doses rather than the traditional 2 doses, which reduces admissions by 37% without increasing revisits) 8, 1, 2
• Oxygen saturation <92% 1, 2
• Age <18 months 1
• Respiratory rate >70 breaths/min 1
• Persistent respiratory distress 1

Common Pitfalls to Avoid

• Never discharge within 2 hours of nebulized epinephrine administration due to rebound risk 2, 7
• Do not use nebulized epinephrine in outpatient settings where immediate return is not feasible 1, 2
• Do not withhold corticosteroids in mild cases - all children with croup benefit from dexamethasone 1, 3
• Avoid routine use of humidified air or cold air therapy - these lack evidence of benefit 2, 3
• Do not prescribe antibiotics routinely - croup is viral in etiology 3, 7
• Avoid neck radiographs unless considering alternative diagnoses 1, 2

Supportive Care

• Administer oxygen to maintain saturation ≥94% if hypoxic 2
• Use antipyretics for comfort 2
• Ensure adequate hydration 2
• Minimize handling to reduce oxygen requirements 2

Discharge Instructions

Children can be discharged when they demonstrate:

• Resolution of stridor at rest 1
• Minimal or no respiratory distress 1
• Adequate oral intake 1
• Parents understand return precautions and can recognize worsening symptoms 1, 2
• Follow-up with primary care if not improving within 48 hours 2