What are the treatment options for croup?

Croup Treatment

All children with croup, regardless of severity, should receive a single dose of oral dexamethasone 0.15-0.6 mg/kg (maximum 10-12 mg), with nebulized epinephrine (0.5 ml/kg of 1:1000 solution, maximum 5 ml) added for moderate to severe cases presenting with stridor at rest or significant respiratory distress. 1, 2

Treatment Algorithm by Severity

Mild Croup

• Oral dexamethasone alone is sufficient for children with mild symptoms (barking cough, minimal stridor only with agitation, no respiratory distress) 1
• Administer dexamethasone 0.15-0.6 mg/kg as a single oral dose (maximum 10-12 mg) 1, 2
• Alternative: Nebulized budesonide 2 mg if oral administration is not feasible 1, 3

Moderate to Severe Croup

• Combine oral dexamethasone with nebulized epinephrine for children presenting with stridor at rest, retractions, or respiratory distress 1, 2, 4
• Nebulized epinephrine dose: 0.5 ml/kg of 1:1000 solution (maximum 5 ml) 1, 4
• Critical timing consideration: Epinephrine effects last only 1-2 hours, requiring close monitoring 4
• Administer supplemental oxygen to maintain saturation ≥94% 4

Observation and Disposition

Post-Epinephrine Monitoring

• Observe for minimum 2 hours after the last dose of nebulized epinephrine to assess for rebound symptoms 4
• Never discharge within 2 hours of epinephrine administration due to risk of rebound airway obstruction 4, 5
• Never use nebulized epinephrine in outpatient settings where immediate return is not feasible 1, 4

Hospitalization Criteria

Consider admission when any of the following are present:

• Need for ≥3 doses of nebulized epinephrine (recent evidence shows waiting until 3 doses reduces hospitalization by 37% without increasing adverse outcomes) 1, 2, 4
• Oxygen saturation <92% 1, 4
• Age <18 months 1, 4
• Respiratory rate >70 breaths/min 1, 4
• Persistent difficulty breathing despite treatment 1

Discharge Criteria

Safe discharge requires ALL of the following:

• Resolution of stridor at rest 1
• Minimal or no respiratory distress 1
• Adequate oral intake 1
• Reliable family able to recognize worsening symptoms and return if needed 1, 4
• At least 2 hours post-epinephrine without rebound symptoms 4

Supportive Care Measures

• Maintain oxygen saturation >94% using nasal cannula, head box, or face mask 1, 4
• Use antipyretics for comfort and fever control 1, 4
• Minimize handling to reduce metabolic and oxygen requirements 1, 4
• Ensure adequate hydration 1

What NOT to Do: Common Pitfalls

• Do not use humidified or cold air therapy - no evidence of benefit 4, 6, 7
• Do not withhold corticosteroids in mild cases - all severities benefit 1, 2
• Do not use antibiotics routinely - croup is viral in etiology 1
• Do not perform chest physiotherapy - not beneficial 4
• Do not obtain routine radiographs unless concerned for alternative diagnosis (bacterial tracheitis, foreign body, epiglottitis) 1, 4
• Do not discharge too early after epinephrine - wait full 2 hours 1, 4

Follow-Up Instructions

• If discharged home, arrange review by primary care provider if symptoms deteriorate or fail to improve within 48 hours 1, 4
• Provide clear return precautions regarding worsening respiratory distress, inability to maintain hydration, or persistent stridor 1

Alternative Diagnoses to Consider

When patients fail to respond to standard treatment, consider:

• Bacterial tracheitis (fever, toxic appearance, failure to respond) 2, 4
• Foreign body aspiration (sudden onset, unilateral findings, no prodrome) 2, 4, 7
• Epiglottitis (drooling, toxic appearance, tripod positioning) 4, 7
• Retropharyngeal or peritonsillar abscess 4, 7