What is the recommended treatment for a 16-month-old patient presenting with croup?

Treatment of Croup in a 16-Month-Old

Administer oral dexamethasone 0.15-0.6 mg/kg (maximum 10-12 mg) as a single dose immediately, regardless of severity, and add nebulized epinephrine (0.5 ml/kg of 1:1000 solution, maximum 5 ml) only if the child has moderate to severe symptoms with stridor at rest or respiratory distress. 1, 2

Initial Assessment

Evaluate the child for:

• Stridor at rest (indicates moderate-severe disease requiring epinephrine) 1, 2
• Respiratory distress (use of accessory muscles, increased work of breathing) 2
• Oxygen saturation (hypoxemia <92% indicates need for admission) 1, 2
• Ability to speak/cry normally and respiratory rate 2

The diagnosis is clinical—avoid radiographic studies unless you suspect an alternative diagnosis like bacterial tracheitis or foreign body aspiration. 1, 2

Treatment Algorithm

All Cases (Mild, Moderate, Severe)

• Give oral dexamethasone 0.15-0.6 mg/kg (maximum 10-12 mg) immediately as a single dose 1, 2
• This is the cornerstone of treatment and reduces inflammation regardless of severity 1, 3
• If oral administration is not feasible, nebulized budesonide 2 mg is equally effective 1, 4

Moderate to Severe Cases (Stridor at Rest or Respiratory Distress)

• Add nebulized epinephrine 0.5 ml/kg of 1:1000 solution (maximum 5 ml) 1, 2, 4
• The effect lasts only 1-2 hours, so observe for at least 2 hours after the last dose to assess for rebound symptoms 1, 2, 4
• Never discharge within 2 hours of epinephrine administration due to rebound risk 1, 2

Supportive Care

• Administer oxygen to maintain saturation ≥94% if hypoxemic 2
• Use antipyretics for comfort 2
• Minimize handling to reduce oxygen requirements 2

Hospitalization Criteria

Consider admission after 3 doses of nebulized epinephrine (not the traditional 2 doses), which reduces hospitalization rates by 37% without increasing revisits. 5, 1, 2 This "3 is the new 2" approach is supported by recent American Academy of Pediatrics guidance. 5, 1

Additional admission criteria include:

• Oxygen saturation <92% 1, 2
• Age <18 months (this patient qualifies) 1, 2
• Respiratory rate >70 breaths/min 1, 2
• Persistent respiratory distress 1

Discharge Criteria

The child can be discharged home if:

• Stridor at rest has resolved 1, 4
• Minimal or no respiratory distress 1, 4
• Adequate oral intake 1
• Parents can recognize worsening symptoms and know to return 1, 2

Instruct parents to follow up with their pediatrician if symptoms worsen or don't improve within 48 hours. 2

Critical Pitfalls to Avoid

• Do not discharge before 2 hours post-epinephrine due to rebound risk 1, 2, 4
• Do not withhold steroids in mild cases—all croup patients benefit 1, 4
• Do not admit after only 1-2 epinephrine doses when a third dose could be given safely in the ED with observation 5, 1
• Do not use nebulized epinephrine in outpatient settings where immediate return is not feasible 1, 2, 4
• Do not use antibiotics routinely—croup is viral 1
• Do not rely on humidified air or cold air treatments—they lack evidence of benefit 1, 2, 6

Special Considerations for This 16-Month-Old

At 16 months, this child falls into a higher-risk category for admission based on age alone. 1, 2 If epinephrine is required, use a neutral head position with a roll under the shoulders to optimize airway patency in children under 2 years. 2

If symptoms fail to respond to standard treatment, consider alternative diagnoses including bacterial tracheitis, foreign body aspiration, or anatomic abnormalities. 1, 2