Immediate Treatment for Stridor on Deep Inspiration in Croup
Administer oral dexamethasone 0.15-0.6 mg/kg (maximum 10-12 mg) as a single dose immediately, and add nebulized epinephrine 0.5 ml/kg of 1:1000 solution (maximum 5 ml) if the child has stridor at rest or significant respiratory distress. 1, 2
Initial Assessment
When a child presents with stridor on deep inspiration due to croup, rapidly assess:
- Severity indicators: presence of stridor at rest (not just on deep inspiration), respiratory rate, use of accessory muscles, oxygen saturation, and ability to speak/cry normally 2
- Life-threatening signs: silent chest, cyanosis, fatigue/exhaustion, or poor respiratory effort—these require immediate escalation 2, 3
- Oxygen saturation: levels <92-93% indicate need for supplemental oxygen and hospitalization 1, 2
Treatment Algorithm by Severity
Mild Croup (Stridor Only on Deep Inspiration/Agitation)
- Oral dexamethasone alone is sufficient at 0.15-0.6 mg/kg (maximum 10-12 mg) as a single dose 1, 2
- The child can typically be managed at home after treatment 1
- Prednisolone 1-2 mg/kg (maximum 40 mg) is an alternative if dexamethasone is unavailable 2
Moderate to Severe Croup (Stridor at Rest or Respiratory Distress)
- Administer both oral dexamethasone AND nebulized epinephrine 1, 2
- Nebulized epinephrine dose: 0.5 ml/kg of 1:1000 solution (maximum 5 ml) 1, 2
- Critical timing consideration: epinephrine's effect is short-lived (1-2 hours), requiring mandatory 2-hour observation period after administration 2, 3, 4
- Dexamethasone onset is approximately 6 hours, so epinephrine bridges the gap until steroids take effect 4
Supportive Care
- Administer supplemental oxygen via nasal cannula, head box, or face mask to maintain oxygen saturation >94% 1, 2
- Position child comfortably—for children under 2 years, neutral head position with roll under shoulders optimizes airway patency 2
- Minimize handling to reduce metabolic and oxygen requirements 2
- Antipyretics for comfort 1, 2
Observation and Disposition
Mandatory Observation Period
- Never discharge within 2 hours of nebulized epinephrine administration due to risk of rebound airway obstruction 2, 3, 4, 5
- This is the most critical pitfall to avoid—rebound symptoms can occur as epinephrine wears off 2, 3
Hospitalization Criteria
Admit if any of the following are present:
- Need for ≥3 doses of nebulized epinephrine (recent evidence supports waiting until 3 doses rather than 2, reducing hospitalizations by 37% without increasing adverse outcomes) 1, 2
- Oxygen saturation <92% 1, 2
- Age <18 months 1, 2
- Respiratory rate >70 breaths/min 1, 2
- Persistent difficulty breathing despite treatment 1, 2
Discharge Criteria
The child can be safely discharged home if ALL of the following are met:
- Resolution of stridor at rest 1, 3
- Minimal or no respiratory distress 1, 3
- Adequate oral intake 1, 3
- At least 2 hours have passed since last nebulized epinephrine dose 3
- Parents understand return precautions and can recognize worsening symptoms 1, 3
Critical Pitfalls to Avoid
- Never use nebulized epinephrine in outpatient settings where immediate return is not feasible—this creates risk for untreated rebound symptoms 6, 2, 3
- Do not discharge too early after epinephrine—the 2-hour observation is mandatory 2, 3, 4
- Do not withhold corticosteroids in mild cases—all children with croup benefit from steroids regardless of severity 1, 2
- Avoid antibiotics—croup is viral and antibiotics have no proven benefit 1, 5
- Do not rely on humidified or cold air treatments—these lack evidence of benefit 2