Management of Croup in Pediatric Patients
Immediate Treatment for All Severity Levels
Administer oral dexamethasone 0.15-0.6 mg/kg (maximum 10-12 mg) as a single dose to every child with croup, regardless of severity. 1, 2 This is the cornerstone of croup management and should never be withheld, even in mild cases. 2
Alternative corticosteroid options include:
- Oral prednisolone 1.0-2.0 mg/kg (maximum 40 mg) if dexamethasone is unavailable 1
- Nebulized budesonide 2 mg when oral administration is not feasible 2
Severity-Based Treatment Algorithm
Mild Croup (No Stridor at Rest)
- Oral dexamethasone alone is sufficient 2
- Observe for 1 hour after administration 3
- Discharge home if no progression of symptoms 2
Moderate to Severe Croup (Stridor at Rest, Respiratory Distress)
- Add nebulized epinephrine 0.5 mL/kg of 1:1000 solution (maximum 5 mL) to oral dexamethasone 1, 2
- Administer oxygen to maintain saturation ≥94% 1, 4
- Monitor for at least 2 hours after the last epinephrine dose before considering discharge 1, 2
- The effect of epinephrine is short-lived (1-2 hours), making this observation period critical 1, 4
Hospitalization Criteria
Consider admission only after 3 doses of nebulized epinephrine are required 1, 2, not the traditional 2 doses. This "3 is the new 2" approach reduces hospitalization rates by 37% without increasing revisits or readmissions. 1, 2
Additional admission criteria include:
- Oxygen saturation <92% 2
- Age <18 months 2
- Respiratory rate >70 breaths/min 2
- Persistent difficulty breathing despite treatment 2
- Unreliable family unable to monitor or return if worsening 1
Critical Pitfalls to Avoid
Never discharge a patient within 2 hours of nebulized epinephrine administration due to rebound symptom risk 1, 2, 5, which is the most common management error.
Never use nebulized epinephrine in outpatient settings where immediate return is not feasible 1, 2, as untreated rebound symptoms can be dangerous.
Never admit after only 1-2 doses of epinephrine when a third dose could be safely administered in the emergency department 2, as this leads to unnecessary hospitalizations.
Never withhold corticosteroids in mild cases 2, as all severity levels benefit from steroid administration.
Discharge Instructions for Parents
Provide clear return precautions including:
- Review child with primary care provider if deteriorating or not improving after 48 hours 1, 2
- Return immediately for worsening stridor, increased work of breathing, inability to drink, or lethargy 1
- Maintain adequate hydration 1
- Use antipyretics for comfort 1, 2
- Avoid agitation, as minimal handling reduces oxygen requirements 1, 2
What NOT to Do
Do not use humidified or cold air therapy 1, as current evidence shows no benefit for respiratory symptoms.
Do not perform chest physiotherapy 1, as it provides no benefit.
Do not routinely prescribe antibiotics 2, as croup is viral in etiology.
Do not obtain radiographic studies 1, 2, 4 unless concerned about alternative diagnoses such as bacterial tracheitis, foreign body aspiration, epiglottitis, or retropharyngeal abscess. 1, 4
When Standard Treatment Fails
If the child fails to respond after 3 doses of nebulized epinephrine, proceed to direct laryngoscopy and bronchoscopy 4 to identify alternative pathology such as bacterial tracheitis or foreign body aspiration. 1, 4 Do not delay this investigation, as clinical assessment is more important than imaging. 4
Special Considerations
For recurrent croup episodes, consider asthma as a differential diagnosis, especially with nocturnal cough worsening, exercise triggers, or family history of atopy. 1 Prophylactic inhaled corticosteroids may be beneficial in these cases. 1
For children under 2 years requiring positioning, use a neutral head position with a roll under the shoulders to optimize airway patency. 1