What is the first line of treatment for a child presenting with croup?

First-Line Treatment for Croup

Administer oral dexamethasone (0.15-0.60 mg/kg, maximum 10 mg) immediately to all children presenting with croup, regardless of severity. 1

Treatment Algorithm

All Patients with Croup (Mild, Moderate, or Severe)

• Give oral corticosteroids immediately as the cornerstone of croup management, with dexamethasone being the preferred agent due to its longer half-life and single-dose convenience 1, 2
• The recommended dose is dexamethasone 0.15-0.60 mg/kg as a single oral dose (maximum 10 mg), or prednisolone 1-2 mg/kg (maximum 40 mg) if dexamethasone is unavailable 1
• Corticosteroids reduce hospital admissions, ICU admissions, and need for intubation, and should be given even in mild cases 3, 4
• The onset of action for dexamethasone is approximately 6 hours, so immediate administration is critical 5

Moderate to Severe Croup (Stridor at Rest or Respiratory Distress)

• Add nebulized epinephrine (0.5 mL/kg of 1:1000 solution, or 0.5 mL of 2.25% racemic epinephrine diluted in 2.5 mL saline) for children with stridor at rest, significant respiratory distress, or use of accessory muscles 1, 2
• The effect of nebulized epinephrine is short-lived (1-2 hours), requiring close monitoring for rebound symptoms 1
• Never discharge a patient within 2 hours of nebulized epinephrine administration due to the risk of rebound airway obstruction 1, 5

Hospitalization Criteria

• Consider admission only after 3 doses of racemic epinephrine are required, as this approach reduces hospitalization rates by 37% without increasing revisits 1, 6
• Additional admission criteria include: oxygen saturation <92%, age <18 months, respiratory rate >70 breaths/min, inability of family to provide appropriate observation, or signs of severe distress 1
• Administer supplemental oxygen to maintain saturation ≥94% using nasal cannula, head box, or face mask 1

Critical Clinical Pitfalls

• Do not use nebulized epinephrine in outpatient settings where the child cannot be observed for at least 2 hours, as rebound symptoms can be life-threatening 1
• Do not obtain neck radiographs routinely, as they are unnecessary and delay treatment; diagnosis is clinical 1, 6
• Do not use humidified or cold air therapy, as current evidence shows no benefit for respiratory symptoms 1
• Do not perform chest physiotherapy, as it provides no benefit 1

Important Differential Diagnoses to Consider

• Bacterial tracheitis, epiglottitis, foreign body aspiration, retropharyngeal abscess, and peritonsillar abscess should be considered if the child fails to respond to standard croup treatment or presents with atypical features 1, 2
• Never perform blind finger sweeps in suspected foreign body aspiration, as this may push objects further into the airway 1

Evidence Quality Note

The 2025 American Academy of Pediatrics guidelines 1 represent the most current and comprehensive approach, emphasizing universal corticosteroid use and the "3 doses before admission" strategy. This approach is supported by a 2022 quality improvement study showing sustained reduction in admissions without increased revisits 6. The traditional practice of admitting after 1-2 doses of epinephrine lacks evidence of clinical benefit and increases healthcare costs unnecessarily 6.