What is the treatment for croup cough?

Treatment for Croup Cough

Administer a single dose of oral dexamethasone 0.6 mg/kg (maximum 10-12 mg) to all children with croup, regardless of severity, and add nebulized epinephrine (0.5 mL of 2.25% racemic epinephrine diluted in 2.5 mL saline) for moderate to severe cases with significant respiratory distress. 1, 2

Corticosteroid Therapy: The Cornerstone of Treatment

• Oral dexamethasone is the preferred first-line treatment at a dose of 0.6 mg/kg (maximum 10-12 mg) because of its ease of administration, easy availability, and low cost 3, 1
• This single dose has been shown to reduce hospitalizations, length of illness, and need for subsequent treatments compared to placebo 3
• Corticosteroids work by reducing airway inflammation, though their onset of action is approximately 6 hours after administration 2
• Intramuscular dexamethasone is reserved for patients who are vomiting or in severe respiratory distress and unable to tolerate oral medication 3, 2
• Nebulized budesonide is effective but less commonly used in favor of oral corticosteroids 3

Nebulized Epinephrine for Moderate to Severe Cases

• Nebulized racemic epinephrine (0.5 mL of 2.25% solution diluted in 2.5 mL saline) is indicated for moderate to severe croup with significant respiratory distress 1, 4
• Epinephrine can quickly reverse airway obstruction and provides rapid symptom relief while waiting for corticosteroids to take effect 2, 4
• Critical pitfall: Patients must be monitored for at least 2 hours after epinephrine administration for rebound airway obstruction 2, 4
• Children requiring two epinephrine treatments should be hospitalized 4

Treatment Algorithm by Severity

Mild Croup

• Single dose of oral dexamethasone 0.6 mg/kg (some clinicians use lower doses of 0.15-0.3 mg/kg for mild disease) 3, 1
• Home care with adequate hydration and fever control 4

Moderate to Severe Croup

• Oral dexamethasone 0.6 mg/kg PLUS nebulized racemic epinephrine 1, 2
• If hypoxemia is present, supplemental oxygen may be helpful 2
• Monitor for at least 2 hours after epinephrine administration 2

Severe Croup (Unable to Take Oral Medication)

• Intramuscular dexamethasone 0.6 mg/kg 2, 4
• Nebulized racemic epinephrine 2
• Consider hospitalization 1

What NOT to Do: Common Pitfalls

• Humidification therapy (mist/humidified air) has not been proven beneficial and does not alter the disease process 5, 1
• Antihistamines, decongestants, and antibiotics have no proven effect on uncomplicated viral croup 4
• Lower steroid dosages (below 0.6 mg/kg) have proven ineffective in treating croup 2
• Do not discharge patients immediately after epinephrine administration without the required 2-hour observation period 2

Clinical Presentation to Recognize

• Croup typically presents with low-grade fever, barking cough, and inspiratory stridor, often preceded by upper respiratory infection symptoms 1, 2
• Most common in children 6 months to 6 years of age, with parainfluenza virus as the most common cause 1, 2
• Always consider alternative diagnoses including bacterial tracheitis, epiglottitis, foreign body aspiration, peritonsillar abscess, retropharyngeal abscess, and angioedema 1, 2

Prognosis and Hospitalization Criteria

• Most episodes are mild, with only 1-8% requiring hospital admission and less than 3% of admitted patients requiring intubation 1
• In most children, symptoms subside quickly with resolution of cough within two days 1
• Corticosteroid-induced complications in croup are rare 3