What is the treatment for a child with croup?

Treatment of Croup in Children

All children with croup should receive a single dose of oral dexamethasone (0.15-0.6 mg/kg, maximum 10-12 mg) regardless of severity, with nebulized epinephrine (0.5 ml/kg of 1:1000 solution, maximum 5 ml) added for moderate to severe cases presenting with stridor at rest or respiratory distress. 1, 2

Initial Assessment

Evaluate the child for key severity indicators:

• Stridor at rest (indicates moderate to severe disease) 1
• Use of accessory muscles and respiratory rate 1
• Oxygen saturation (maintain ≥94%) 1
• Ability to speak/cry normally 1

Critical pitfall: Do not obtain radiographic studies unless you suspect an alternative diagnosis such as bacterial tracheitis, epiglottitis, foreign body aspiration, or retropharyngeal abscess. 1, 2, 3

Treatment Algorithm

Mild Croup (No stridor at rest)

• Administer oral dexamethasone 0.15-0.6 mg/kg (maximum 10-12 mg) as a single dose 1, 2, 4
• Observe for 2-3 hours to ensure symptom improvement 5
• No nebulized treatments needed 5

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

• Give oral dexamethasone immediately (same dosing as above) 1, 2
• Add nebulized epinephrine 0.5 ml/kg of 1:1000 solution (maximum 5 ml) 1, 2, 4
• Observe for at least 2 hours after the last epinephrine dose to monitor for rebound symptoms 1, 2
• Administer oxygen to maintain saturation ≥94% 1, 2

Alternative corticosteroid option: Nebulized budesonide 2 mg is equally effective as oral dexamethasone when oral administration is not feasible. 2, 6

Critical Timing Considerations

The effect of nebulized epinephrine is short-lived, lasting only 1-2 hours, making close monitoring essential. 1, 2 Dexamethasone has an onset of action of approximately 6 hours, which is why epinephrine provides the immediate bridge until steroids take effect. 7

Major pitfall to avoid: Never discharge a patient within 2 hours of nebulized epinephrine administration due to the risk of rebound symptoms. 1, 2, 5 Never use nebulized epinephrine in outpatient settings where immediate return is not feasible. 1, 2

Hospitalization Criteria

Consider admission when:

• ≥3 doses of nebulized epinephrine are required (this threshold reduces hospitalization rates by 37% without increasing revisits or readmissions) 1, 2, 5
• Oxygen saturation <92% 2
• Age <18 months 2
• Respiratory rate >70 breaths/min 2
• Persistent difficulty breathing 2

Discharge Criteria

The child can be discharged home when:

• Stridor at rest has resolved 2, 5
• Minimal or no respiratory distress 2, 5
• Adequate oral intake 2, 5
• Parents can recognize worsening symptoms and return if needed 2, 5
• At least 2 hours have passed since the last epinephrine dose 1, 2

Instruct parents to follow up with their primary care provider if the child is deteriorating or not improving after 48 hours. 1, 2

What NOT to Do

• Do not use humidified or cold air therapy - current evidence shows no benefit 1, 2
• Do not use antibiotics routinely - croup is viral in etiology (most commonly parainfluenza viruses) 1, 2, 4
• Do not use normal saline nebulization as primary treatment 5
• Do not perform chest physiotherapy - it provides no benefit 1
• Do not use lower doses of dexamethasone (<0.15 mg/kg) as they have proven ineffective 7

Positioning for Young Children

For children under 2 years, use a neutral head position with a roll under the shoulders to optimize airway patency. 1