First-Line Treatment for Croup
Oral dexamethasone is the first-line treatment for all patients presenting with croup symptoms, regardless of severity, at a dose of 0.15-0.6 mg/kg (maximum 10-12 mg) as a single dose. 1, 2
Treatment Algorithm by Severity
Mild Croup
- Administer oral dexamethasone 0.15-0.6 mg/kg as a single dose (this alone is sufficient for mild cases) 1, 3
- Observe for 2-3 hours to ensure symptoms are improving 2
- No nebulized treatments are needed 2
Moderate to Severe Croup
- Give oral dexamethasone PLUS nebulized epinephrine (0.5 ml/kg of 1:1000 solution, maximum 5 ml) 1, 2, 4
- The epinephrine effect is short-lived (1-2 hours), requiring close monitoring 2
- Observe for at least 2 hours after the last epinephrine dose to assess for symptom rebound 2
Alternative Corticosteroid Option
- Nebulized budesonide 2 mg is equally effective as oral dexamethasone when oral administration is not feasible (e.g., vomiting, severe distress) 1, 5, 6
Critical Pitfalls to Avoid
- Never discharge patients shortly after nebulized epinephrine without the mandatory 2-hour observation period due to rebound symptom risk 1, 2
- Do not withhold corticosteroids in mild cases - they benefit all severity levels 1, 2
- Avoid using prednisolone instead of dexamethasone - prednisolone results in 22% higher re-presentation rates (29% vs 7%) 7
- Do not use humidified air or cold air therapy - these lack evidence of benefit 3, 5
- Avoid routine antibiotics - croup is viral in etiology 1
Hospitalization Criteria
Consider admission when patients require: 1, 2
- ≥3 doses of nebulized epinephrine (recent AAP guidelines support waiting until 3 doses rather than 2, reducing hospitalizations by 37% without increasing adverse outcomes)
- Oxygen saturation <92%
- Age <18 months
- Respiratory rate >70 breaths/min
- Persistent difficulty breathing
Discharge Criteria
Patients can be discharged when they demonstrate: 1, 2
- Resolution of stridor at rest
- Minimal or no respiratory distress
- Adequate oral intake
- Parents understand return precautions and can recognize worsening symptoms