What are the treatment options for croup?

Croup Treatment

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 (0.5 ml/kg of 1:1000 solution, maximum 5 ml) only for moderate to severe cases with stridor at rest or significant respiratory distress. 1

Treatment Algorithm by Severity

Mild Croup

• Give oral dexamethasone alone (0.15-0.6 mg/kg, maximum 10-12 mg as a single dose) 1
• No nebulized treatments needed 2
• Observe for 2-3 hours to ensure symptoms are improving 2
• Discharge if stridor resolves at rest, minimal respiratory distress, adequate oral intake, and parents can recognize worsening symptoms 2

Moderate to Severe Croup (stridor at rest, respiratory distress, accessory muscle use)

• Administer oral dexamethasone immediately (same dosing as above) 1
• Add nebulized epinephrine 0.5 ml/kg of 1:1000 solution (maximum 5 ml) 1, 2
• Epinephrine effects last only 1-2 hours, requiring close monitoring 2, 3
• Observe for at least 2 hours after the last epinephrine dose to assess for rebound symptoms 2, 3
• Provide supplemental oxygen to maintain saturation ≥94% 3

Alternative Corticosteroid Option

• Nebulized budesonide 2 mg is equally effective as oral dexamethasone when oral administration is not feasible 1, 4
• Budesonide reduces symptoms within the first 2 hours 2

Hospitalization Criteria

Consider admission only after 3 doses of nebulized epinephrine rather than the traditional 2 doses—this approach reduces hospitalization rates by 37% without increasing revisits or readmissions 1, 3

Additional admission criteria include:

• Oxygen saturation <92% 1, 3
• Age <18 months 1
• Respiratory rate >70 breaths/min 1
• Persistent difficulty breathing despite treatment 1
• Silent chest, cyanosis, fatigue/exhaustion, or poor respiratory effort 3

Critical Pitfalls to Avoid

• Never discharge within 2 hours of nebulized epinephrine due to risk of rebound symptoms 1, 2, 3
• Never use nebulized epinephrine in outpatient settings where immediate return is not feasible 1, 2, 3
• 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
• Do not skip corticosteroids in mild cases—they reduce symptoms and hospitalization need even in mild disease 2, 5
• Avoid humidified or cold air treatments—they lack evidence of benefit 3, 5, 6
• Do not use antibiotics routinely—croup is viral in etiology 1
• Do not obtain radiographs unless concerned for alternative diagnosis like bacterial tracheitis, foreign body aspiration, or epiglottitis 1, 3

Supportive Care

• Administer oxygen via nasal cannula, head box, or face mask to maintain saturation >94% 3
• Use antipyretics for comfort 1, 3
• Minimize handling to reduce metabolic and oxygen requirements 1, 3
• Ensure parents understand return precautions and signs of deterioration 1, 3

Discharge Instructions

• Review by general practitioner if deteriorating or not improving after 48 hours 3
• Provide clear information on managing fever, preventing dehydration, and identifying worsening symptoms 3
• Ensure family is reliable and able to monitor and return if needed 3