Treatment of Croup in Pediatric Patients
First-Line Treatment for All Severity Levels
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. 1, 2 This recommendation is based on clear evidence that corticosteroids decrease symptoms, reduce hospitalization rates, and have minimal adverse effects with a single dose. 3
- Oral administration is the preferred route over intramuscular injection 4
- The 0.15 mg/kg dose appears equally effective as the higher 0.6 mg/kg dose 3
- Nebulized budesonide 2 mg is an alternative when oral administration is not feasible and has equivalent efficacy to oral dexamethasone 1, 3
Severity-Based Treatment Algorithm
Mild Croup
- Administer oral dexamethasone alone 1
- Observe for 2-3 hours to ensure symptoms are improving 5
- No nebulized treatments are needed 5
Moderate to Severe Croup
- Administer oral dexamethasone PLUS nebulized epinephrine 1, 2
- Nebulized epinephrine dose: 0.5 ml/kg of 1:1000 solution (maximum 5 ml) 1, 5
- Provide supplemental oxygen to maintain saturation ≥94% 1, 6
- Observe for at least 2 hours after the last epinephrine dose to monitor for rebound symptoms 5, 7
Updated Hospitalization Criteria
Consider hospitalization only after 3 doses of nebulized epinephrine rather than the traditional 2 doses. 8, 1 This updated approach reduces hospitalization rates by 37% without increasing revisits or readmissions. 8, 1
Additional admission criteria include:
- Oxygen saturation <92% 1
- Age <18 months 1
- Respiratory rate >70 breaths/min 1
- Persistent difficulty breathing despite treatment 1
- Persistent stridor at rest despite treatment 5
Critical Pitfalls to Avoid
- Never discharge patients within 2 hours of receiving nebulized epinephrine due to the risk of rebound airway obstruction, as epinephrine effects last only 1-2 hours 5, 7
- Do not use nebulized epinephrine in outpatient settings where adequate observation cannot be provided 1, 5
- Do not admit after only 1-2 doses of epinephrine when a third dose could be safely administered in the emergency department with appropriate observation 1
- Avoid failing to administer corticosteroids even in mild cases 5
- Do not routinely use antibiotics, as croup is viral in etiology 2
- Avoid relying on humidified air or mist therapy, which lack evidence of benefit 2, 4
Discharge Criteria
Patients may be discharged when they demonstrate:
- Resolution of stridor at rest 1, 5
- Minimal or no respiratory distress 1, 5
- Adequate oral intake 1, 5
- Parents understand warning signs and when to return 1, 5
When Standard Treatment Fails
If a patient fails to respond after 3 doses of racemic epinephrine, consider alternative diagnoses including bacterial tracheitis, foreign body aspiration, epiglottitis, peritonsillar abscess, or retropharyngeal abscess. 6, 2 Direct laryngoscopy and bronchoscopy should be performed to visualize the airway and identify alternative pathology. 6