Treatment of Croup
Administer oral dexamethasone 0.15-0.6 mg/kg (maximum 10-12 mg) as a single dose to all children with croup regardless of severity, and add nebulized epinephrine for moderate to severe cases with stridor at rest or respiratory distress. 1
Initial Treatment Algorithm
All Severity Levels
- Give oral corticosteroids immediately to every child presenting with croup symptoms, even mild cases 1, 2
- Dexamethasone 0.15-0.6 mg/kg orally (maximum 10-12 mg) is the preferred agent 1, 2
- Alternative: Prednisolone 1-2 mg/kg (maximum 40 mg) if dexamethasone unavailable 2
- Alternative: Nebulized budesonide 2 mg has equivalent efficacy when oral administration is not feasible 1, 3
Mild Croup
- Oral dexamethasone alone is sufficient 1
- Observe for 2-3 hours to ensure symptoms are improving 3
- No nebulized treatments needed 3
Moderate to Severe Croup (Stridor at Rest or Respiratory Distress)
- Add nebulized epinephrine 0.5 ml/kg of 1:1000 solution (maximum 5 ml) 1, 2, 3
- Epinephrine effects last only 1-2 hours, requiring close monitoring 2, 3
- Observe for minimum 2 hours after each epinephrine dose to assess for rebound symptoms 2, 3
- Administer oxygen to maintain saturation ≥94% 2
Hospitalization Criteria
Consider admission only after 3 doses of nebulized epinephrine rather than the traditional 2 doses—this "3 is the new 2" approach reduces hospitalizations by 37% without increasing revisits or readmissions 4, 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 Too Early After Epinephrine
- Do not discharge within 2 hours of nebulized epinephrine administration due to rebound risk 1, 2, 3
- Never use nebulized epinephrine in outpatient settings where immediate return is not feasible 2, 3
Never Skip Corticosteroids in Mild Cases
- Failing to administer corticosteroids even in mild croup is a common error 1, 3
- Evidence clearly demonstrates benefit across all severity levels 1
Avoid Premature Admission
- Admitting after only 1-2 doses of epinephrine when a third dose could be given safely in the ED wastes resources 1
- 80% of admitted patients require no further interventions after admission 4
Discharge Criteria
Children can be discharged when:
- Resolution of stridor at rest 1, 3
- Minimal or no respiratory distress 1, 3
- Adequate oral intake 1, 3
- Parents able to recognize worsening symptoms and return if needed 1, 2, 3
- Review by general practitioner if deteriorating or not improving after 48 hours 2
What NOT to Do
- Avoid imaging unless concerned for alternative diagnosis (bacterial tracheitis, foreign body, epiglottitis) 1, 2
- Do not use humidified or cold air therapy—no evidence of benefit 2
- Do not use antibiotics routinely—croup is viral 1
- Do not perform chest physiotherapy 2
Alternative Diagnoses to Consider
If patient fails to respond to standard treatment, consider: