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

First-Line Treatment for Croup in Children

The first-line treatment for all children with croup, regardless of severity, is a single dose of oral dexamethasone (0.15-0.60 mg/kg, maximum 10-12 mg), with nebulized epinephrine (0.5 ml/kg of 1:1000 solution, maximum 5 ml) added for moderate to severe cases with stridor at rest or respiratory distress. 1, 2

Treatment Algorithm by Severity

All Cases of Croup (Mild, Moderate, and Severe)

• Administer oral corticosteroids immediately - this is the cornerstone of croup management and should be given to every child with croup, even those with mild symptoms 1, 2, 3
• Dexamethasone 0.15-0.60 mg/kg as a single oral dose (maximum 10-12 mg) is the preferred corticosteroid 1, 2, 4
• Alternative: Prednisolone 1.0-2.0 mg/kg (maximum 40 mg) if dexamethasone is unavailable 1, 5
• Alternative: Nebulized budesonide 2 mg is equally effective when oral administration is not feasible 2

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

• Add nebulized epinephrine to the oral corticosteroid regimen 1, 2, 5
• Dosage: 0.5 ml/kg of 1:1000 epinephrine solution (maximum 5 ml) via nebulizer 1, 2
• Alternative formulation: 4 mL of undiluted 1:1000 adrenaline via nebulizer 5
• Critical timing consideration: The effect of nebulized epinephrine is short-lived, lasting only 1-2 hours 1, 2
• Mandatory observation period: Monitor the child for at least 2 hours after the last dose of nebulized epinephrine to assess for rebound symptoms 1, 2

Oxygen Support

• Administer oxygen via nasal cannulae, head box, or face mask to maintain oxygen saturation above 94% 1, 2
• Oxygen saturation <92% is an indicator for hospital admission 1, 2

Hospitalization Criteria

Consider hospital admission when any of the following are present: 1, 2

• Need for ≥3 doses of nebulized epinephrine (updated from the traditional 2 doses) 1, 2
• Oxygen saturation <92% 1, 2
• Age <18 months 1, 2
• Respiratory rate >70 breaths/min 1, 2
• Persistent difficulty in breathing 1, 2
• Family unable to provide appropriate observation or supervision 1

Important update: Recent evidence shows that waiting until 3 doses of racemic epinephrine are needed (rather than the traditional 2 doses) reduces hospitalization rates by 37% without increasing revisits or readmissions 1, 2

Critical Pitfalls to Avoid

• Never discharge a patient within 2 hours of nebulized epinephrine administration due to the risk of rebound symptoms 1, 2
• Never use nebulized epinephrine in outpatient settings where immediate return is not feasible, as this can lead to untreated rebound symptoms 1, 2, 6
• Do not fail to administer corticosteroids in mild cases - even mild croup benefits from steroid treatment 2, 4
• Do not admit patients prematurely after only 1-2 doses of epinephrine when they could safely receive a third dose in the emergency department with appropriate observation 2
• Do not use antibiotics routinely - croup is typically viral in etiology 2, 3
• Do not rely on cold air or humidified air treatments - these lack evidence of benefit 1, 2

Supportive Care Measures

• Antipyretics can be used to keep the child comfortable and help with coughing 1, 2
• Minimal handling may reduce metabolic and oxygen requirements in ill children 1, 2
• Ensure adequate hydration 7
• Chest physiotherapy is not beneficial and should not be performed 1

Discharge Criteria and Follow-Up

Safe discharge requires: 2

• Resolution of stridor at rest 2
• Minimal or no respiratory distress 2
• Adequate oral intake 2
• Parents able to recognize worsening symptoms and return if needed 2

Follow-up instructions: If discharged home, the child should be reviewed by a general practitioner if deteriorating or not improving after 48 hours 1, 2

Differential Diagnoses to Consider

If the child fails to respond to standard croup treatment, consider alternative diagnoses: 1, 6, 3

• Bacterial tracheitis 1, 6, 3
• Foreign body aspiration 1, 6, 3
• Epiglottitis 3
• Retropharyngeal or peritonsillar abscess 3

Diagnostic approach for treatment failure: Direct visualization by laryngoscopy is the most important investigation to rule out croup-mimicking conditions when standard treatment fails 6