What is the first-line treatment for a child presenting with croup?

First-Line Treatment for Croup

Oral corticosteroids should be administered immediately to all children presenting with croup, regardless of severity, with dexamethasone 0.15-0.60 mg/kg as a single oral dose (maximum 10 mg) being the preferred agent. 1

Treatment Algorithm by Severity

Mild Croup (No Stridor at Rest)

• Administer oral dexamethasone 0.15-0.60 mg/kg (maximum 10 mg) as a single dose 1
• Observe for 2-3 hours to ensure symptoms are improving 2
• No nebulized treatments are needed for mild cases 2
• Discharge home if stridor resolves and parents can recognize worsening symptoms 2

Moderate to Severe Croup (Stridor at Rest or Respiratory Distress)

• Give oral dexamethasone immediately (same dosing as above) 1
• Add nebulized epinephrine 0.5 ml/kg of 1:1000 solution (maximum 5 ml) 1, 2
• The epinephrine effect is short-lived, lasting only 1-2 hours, requiring close monitoring 1, 2
• Patients must be observed for at least 2 hours after the last dose of nebulized epinephrine to assess for rebound symptoms 1, 2

Alternative Corticosteroid Options

• If dexamethasone is unavailable, use prednisolone 1-2 mg/kg (maximum 40 mg) 1
• Nebulized budesonide 2 mg can be given to children who cannot tolerate oral dexamethasone 3

Supportive Care Measures

• Administer oxygen via nasal cannulae, head box, or face mask to maintain oxygen saturation ≥94% 1
• Position children under 2 years in a neutral head position with a roll under the shoulders to optimize airway patency 1
• Minimize handling to reduce metabolic and oxygen requirements 1
• Use antipyretics to keep the child comfortable 1

Hospitalization Criteria

• Consider admission when three or more doses of racemic epinephrine are required 1, 2
• This approach can reduce hospitalization rates by 37% without increasing revisits or readmissions 1, 2
• Other admission indicators include oxygen saturation <92%, age <18 months, respiratory rate >70 breaths/min, or inability of family to provide appropriate observation 1

Critical Pitfalls to Avoid

• Never discharge a patient within 2 hours of nebulized epinephrine administration due to risk of rebound symptoms 1, 2
• Never use nebulized epinephrine in outpatient settings where immediate return is not feasible 1, 2
• Do not fail to administer corticosteroids in mild cases—all severities benefit 2
• Do not perform chest physiotherapy, as it provides no benefit 1
• Avoid humidified or cold air therapy, as current evidence shows no benefits 1

Discharge Planning

• Ensure resolution of stridor at rest and minimal respiratory distress 2
• Confirm parents can recognize worsening symptoms and know to return if needed 1, 2
• Advise review by a general practitioner if deteriorating or not improving after 48 hours 1
• Provide families with information on managing fever, preventing dehydration, and identifying signs of deterioration 1

Important Differential Diagnoses to Consider

• Bacterial tracheitis, epiglottitis, foreign body aspiration, and retropharyngeal or peritonsillar abscess should be considered in atypical presentations 1
• Radiographic studies are generally unnecessary unless there is concern for an alternative diagnosis 1
• Never perform blind finger sweeps in suspected foreign body aspiration, as this may push objects further into the pharynx 1