Croup: Symptoms and Treatment
Clinical Presentation
Croup presents with a distinctive barking or brassy cough, inspiratory stridor, hoarse voice, and varying degrees of respiratory distress due to upper airway obstruction. 1, 2
Key Symptoms to Recognize:
- Barking or "seal-like" cough - the hallmark feature 3, 4
- Inspiratory stridor - high-pitched breathing sound on inhalation 5, 6
- Hoarse voice from laryngeal inflammation 5
- Respiratory distress with use of accessory muscles in moderate-severe cases 2
- Low-grade fever and preceding upper respiratory symptoms (coryza, congestion) 7, 4
- Symptoms typically worsen at night and often resolve within 48 hours 4
Severity Assessment Indicators:
- Ability to speak/cry normally 2
- Presence of stridor at rest (indicates moderate-severe disease) 2, 6
- Respiratory rate and heart rate 2
- Oxygen saturation 2
- Use of accessory muscles 2
- Life-threatening signs: silent chest, cyanosis, fatigue/exhaustion, poor respiratory effort 2
Treatment Algorithm
All Cases (Mild to Severe):
Administer oral dexamethasone 0.15-0.6 mg/kg (maximum 10-12 mg) as a single dose immediately for all children with croup, regardless of severity. 1, 2
- Prednisolone 1-2 mg/kg (maximum 40 mg) is an alternative if dexamethasone unavailable 2
- Nebulized budesonide 2 mg is equally effective when oral administration not feasible 1
Mild Croup:
- Oral dexamethasone alone is sufficient 1
- Reassess in 1 hour 8
- Minimal handling to reduce oxygen requirements 1, 9
Moderate to Severe Croup (stridor at rest or respiratory distress):
Add nebulized epinephrine 0.5 ml/kg of 1:1000 solution (maximum 5 ml) to corticosteroid therapy. 1, 2
- Alternative dosing: 4 mL of adrenaline 1:1000 undiluted via nebulizer 8
- Critical: Epinephrine effects last only 1-2 hours 2
- Mandatory 2-hour observation period after last epinephrine dose to monitor for rebound symptoms 1, 2
Oxygen Therapy:
- Administer oxygen via nasal cannula, head box, or face mask to maintain saturation ≥94% 1, 2
- Agitation may indicate hypoxia requiring oxygen 2
Hospitalization Criteria
Consider admission after 3 doses of nebulized epinephrine (not the traditional 2 doses), which reduces hospitalization by 37% without increasing adverse outcomes. 1, 2
Additional Admission Indicators:
- Oxygen saturation <92% 1, 2
- Age <18 months 1, 2
- Respiratory rate >70 breaths/min 1, 2
- Persistent difficulty breathing 1
Discharge Criteria
- Resolution of stridor at rest 1
- Minimal or no respiratory distress 1
- Adequate oral intake 1
- Reliable family able to monitor and recognize worsening symptoms 1, 2
- Must complete 2-hour observation after last epinephrine dose 1, 2
- Follow-up with primary care if not improving after 48 hours 1, 2
Critical Pitfalls to Avoid
Never discharge within 2 hours of nebulized epinephrine administration due to risk of rebound airway obstruction requiring immediate intervention. 1, 2
- Never use nebulized epinephrine in outpatient settings where immediate return is not feasible 1, 2
- Never admit after only 1-2 doses of epinephrine when a third dose could be safely administered in the emergency department 1
- Do not fail to administer corticosteroids in mild cases 1
- Do not use antibiotics routinely - croup is viral 2, 4
- Do not rely on humidified air or cold air as primary treatment - evidence shows no benefit 2, 9
- Never use antihistamines - they are ineffective for viral croup and associated with documented fatalities in young children 9
- Avoid chest physiotherapy - not beneficial 2
- Do not perform blind finger sweeps if foreign body suspected - may push object deeper 2
Differential Diagnoses to Exclude
When symptoms don't respond to standard treatment or presentation is atypical, consider:
- Bacterial tracheitis 2
- Epiglottitis 2, 4
- Foreign body aspiration 2, 4
- Retropharyngeal or peritonsillar abscess 2, 4
- Pertussis 2
Radiographic studies are generally unnecessary unless alternative diagnosis suspected. 1, 2
Special Considerations
Recurrent Croup:
- Consider asthma as differential, especially with nocturnal worsening, exercise triggers, or family history of atopy 2
- Prophylactic inhaled corticosteroids may benefit children with recurrent episodes and atopy 2
Positioning:
- For children under 2 years, use neutral head position with roll under shoulders to optimize airway patency 2