Treatment of Croup in Pediatric Patients
Initial Management
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, with nebulized epinephrine reserved for moderate to severe cases. 1
Severity-Based Treatment Algorithm
Mild Croup (stridor only with agitation, no respiratory distress):
- Administer oral dexamethasone 0.15-0.6 mg/kg as a single dose 1, 2
- Observe for 1 hour after steroid administration 3
- Discharge home if no progression of symptoms 1
Moderate to Severe Croup (stridor at rest, respiratory distress with retractions):
- Give oral dexamethasone 0.15-0.6 mg/kg immediately 1, 2
- Add nebulized epinephrine 0.5 mL/kg of 1:1000 solution (maximum 5 mL) 1, 4
- The effect of nebulized epinephrine lasts only 1-2 hours, requiring mandatory observation for at least 2 hours after the last dose to monitor for rebound symptoms 1, 4
- Administer oxygen to maintain saturation ≥94% 1, 4
Alternative corticosteroid option: Nebulized budesonide 2 mg can be used when oral administration is not feasible 1, 2
Updated Hospitalization Criteria
The most recent evidence from the American Academy of Pediatrics (2022) supports a paradigm shift: consider hospitalization only after 3 doses of nebulized epinephrine rather than the traditional 2 doses. 5, 1 This "3 is the new 2" approach reduces hospitalization rates by 37% without increasing revisits or readmissions 5, 1.
Additional admission criteria include:
- Oxygen saturation <92% 1
- Age <18 months 1
- Respiratory rate >70 breaths/min 1
- Persistent respiratory distress despite treatment 1
Critical Pitfalls to Avoid
Never discharge a patient within 2 hours of nebulized epinephrine administration due to the risk of rebound airway obstruction. 1, 4 This is the most common and dangerous error in croup management.
- Do not use nebulized epinephrine in outpatient settings where immediate return is not feasible 1, 4
- Avoid admitting patients after only 1-2 doses of epinephrine when they could safely receive a third dose in the emergency department 1
- Do not withhold corticosteroids in mild cases—all severities benefit from dexamethasone 1, 6
- Avoid routine use of antibiotics, as croup is viral in etiology 6
- Do not rely on humidified air or cold air treatments, which lack evidence of benefit 1, 2
- Radiographic studies are generally unnecessary and should be avoided unless alternative diagnoses are suspected 1, 4
Discharge Instructions
Discharge is appropriate when:
- Stridor has resolved at rest 1
- Minimal or no respiratory distress present 1
- Adequate oral intake maintained 1
- Parents can recognize worsening symptoms and know to return if needed 1
Instruct families to return immediately for worsening respiratory distress, inability to drink, or cyanosis 1. If not improving after 48 hours, the child should be reviewed by their primary care provider 1, 4.
When Standard Treatment Fails
If a patient fails to respond to standard treatment (including 3 doses of epinephrine), consider alternative diagnoses such as bacterial tracheitis, foreign body aspiration, or other airway pathology 7, 4. Direct laryngoscopy should be performed to visualize the airway and identify the true pathology 7.