What is the first line treatment for croup?

First-Line Treatment for Croup

Oral corticosteroids (specifically dexamethasone 0.15-0.6 mg/kg, maximum 10-12 mg as a single dose) are the first-line treatment for all cases of croup, regardless of severity. 1, 2, 3

Treatment Algorithm by Severity

Mild Croup

• Administer oral dexamethasone 0.15-0.6 mg/kg (maximum 10-12 mg) as a single dose 1, 2
• This is sufficient as monotherapy for mild cases 1
• Observe for 2-3 hours to ensure symptoms are improving 4
• No nebulized treatments are needed for mild disease 4

Moderate to Severe Croup

• Give oral dexamethasone first, then add nebulized epinephrine (0.5 ml/kg of 1:1000 solution, maximum 5 ml) 1, 2, 4
• Nebulized epinephrine provides rapid symptom relief but effects last only 1-2 hours 1, 2, 4
• Patients must be observed for at least 2 hours after the last epinephrine dose to monitor for rebound symptoms 2, 4

Alternative Corticosteroid Options

• Nebulized budesonide 2 mg is equally effective as oral dexamethasone when oral administration is not feasible 1, 5
• Prednisolone 1-2 mg/kg (maximum 40 mg) can be used if dexamethasone is unavailable 2
• Intramuscular dexamethasone 0.6 mg/kg is effective but oral route is preferred 5, 6

Hospitalization Criteria

Consider admission only after 3 doses of nebulized epinephrine are required - this updated threshold (rather than the traditional 2 doses) reduces hospitalizations by 37% without increasing revisits or readmissions 7, 1, 2

Additional admission criteria include:

• Oxygen saturation <92% 1, 2
• Age <18 months 1, 2
• Respiratory rate >70 breaths/min 1, 2
• Persistent difficulty breathing 1

Critical Pitfalls to Avoid

• Never discharge a patient within 2 hours of nebulized epinephrine administration due to high risk of rebound airway obstruction 2, 4, 6
• Never use nebulized epinephrine in outpatient settings where immediate return is not feasible 1, 2, 4
• Do not withhold corticosteroids in mild cases - they benefit all severity levels 1, 4, 3
• Avoid antibiotics as croup is viral in etiology 1, 8
• Do not rely on humidified air or mist therapy - these lack evidence of benefit 2, 9, 3

Supportive Care

• Administer oxygen to maintain saturation ≥94% if needed 1, 2
• Use antipyretics for comfort 1, 2
• Minimize handling to reduce oxygen requirements 1, 2
• Ensure adequate hydration 2

Discharge Instructions

Discharge is appropriate when:

• Stridor at rest has resolved 1, 4
• Minimal or no respiratory distress present 1, 4
• Adequate oral intake achieved 1, 4
• Parents can recognize worsening symptoms and know to return if needed 1, 2, 4
• Instruct parents to follow up with primary care if not improving after 48 hours 1, 2