What is the treatment for croup?

Treatment of Croup

All children with croup should receive oral dexamethasone 0.15-0.6 mg/kg (maximum 10-12 mg) as a single dose regardless of severity, with nebulized epinephrine reserved for moderate to severe cases. 1

Initial Assessment

Evaluate the child's severity by assessing:

• Presence of stridor at rest (indicates moderate to severe disease) 2
• Respiratory rate and use of accessory muscles 2
• Oxygen saturation (hypoxemia if <92-93%) 1, 2
• Ability to speak or cry normally 2
• Signs of life-threatening disease: silent chest, cyanosis, fatigue/exhaustion, or poor respiratory effort 2

Avoid radiographic studies unless you suspect an alternative diagnosis such as bacterial tracheitis, epiglottitis, foreign body aspiration, or retropharyngeal abscess. 1, 2

Treatment Algorithm by Severity

Mild Croup

• Administer oral dexamethasone 0.15-0.6 mg/kg (maximum 10-12 mg) as a single dose 1
• Observe for 2-3 hours to ensure symptoms are improving 3
• No nebulized treatments needed 3

Moderate to Severe Croup (stridor at rest or respiratory distress)

• Give oral dexamethasone 0.15-0.6 mg/kg (maximum 10-12 mg) immediately 1, 2
• Add nebulized epinephrine 0.5 mL/kg of 1:1000 solution (maximum 5 mL) 1, 2
• The effect of nebulized epinephrine lasts only 1-2 hours, requiring close monitoring for rebound symptoms 2, 3
• Observe for at least 2 hours after the last epinephrine dose before considering discharge 2, 3

Severe/Life-Threatening Croup

• Administer nebulized epinephrine immediately 4
• Give dexamethasone (onset of action is approximately 6 hours) 5
• Provide supplemental oxygen to maintain saturation ≥94% 2
• Arrange immediate hospital transfer via ambulance 4

Hospitalization Criteria

Admit patients who require 3 or more doses of nebulized epinephrine rather than the traditional 2 doses—this approach reduces hospitalization rates by 37% without increasing revisits or readmissions. 6, 1, 2

Additional admission criteria include:

• Oxygen saturation <92% 1
• Age <18 months 1
• Respiratory rate >70 breaths/min 1
• Persistent difficulty breathing 1

Discharge Criteria

Discharge is appropriate when:

• Stridor at rest has resolved 1, 3
• Minimal or no respiratory distress present 1, 3
• Adequate oral intake maintained 1, 3
• Parents can recognize worsening symptoms and know to return if needed 1, 2, 3

Instruct families to follow up with their general practitioner if the child deteriorates or does not improve after 48 hours. 2

Alternative Corticosteroid Options

Nebulized budesonide 2 mg is equally effective as oral dexamethasone and may be used when oral administration is not feasible. 1

Prednisolone 1-2 mg/kg (maximum 40 mg) can be substituted if dexamethasone is unavailable. 2

Critical Pitfalls to Avoid

• Never discharge a patient within 2 hours of nebulized epinephrine administration due to the risk of rebound airway obstruction 2, 3, 5
• Never use nebulized epinephrine in outpatient settings where immediate return is not feasible, as rebound symptoms can occur when the medication wears off 1, 2, 3
• Do not withhold corticosteroids in mild cases—all severities benefit from steroid treatment 1, 3
• Avoid using antibiotics routinely, as croup is viral in etiology 1
• Do not rely on humidified air or cold air treatments, which lack evidence of benefit 2, 7
• Ensure clear return precautions are provided to parents 3

Supportive Care

• Administer oxygen via nasal cannula, head box, or face mask to maintain saturation >94% 1, 2
• Use antipyretics to keep the child comfortable 1, 2
• Minimize handling to reduce metabolic and oxygen requirements 1, 2
• Ensure adequate hydration 2
• For children under 2 years requiring positioning, use a neutral head position with a roll under the shoulders to optimize airway patency 2