What is the treatment for a 5-year-old patient with croup?

Treatment of Croup in a 5-Year-Old Child

All children with croup, regardless of severity, should receive a single dose of oral dexamethasone 0.15-0.60 mg/kg (maximum 10 mg), with nebulized epinephrine reserved for moderate-to-severe cases presenting with stridor at rest or significant respiratory distress. 1

Initial Assessment

Immediately evaluate the child for severity indicators:

• Stridor at rest (indicates moderate-to-severe disease requiring epinephrine) 1
• Respiratory rate and work of breathing (retractions, nasal flaring, use of accessory muscles) 1
• Oxygen saturation (hypoxemia if <92-94%) 1
• Ability to speak/cry normally and presence of barking cough 1
• Life-threatening signs: silent chest, cyanosis, fatigue/exhaustion, or poor respiratory effort 1

Radiographic studies are unnecessary and should be avoided unless considering alternative diagnoses such as foreign body aspiration, bacterial tracheitis, or epiglottitis. 1

Treatment Algorithm by Severity

Mild Croup (No Stridor at Rest)

• Administer oral dexamethasone 0.15-0.60 mg/kg (maximum 10 mg) as a single dose 1, 2
• Alternative: prednisolone 1-2 mg/kg (maximum 40 mg) if dexamethasone unavailable 1
• Review in 1 hour for clinical improvement 3
• Provide supportive care with adequate hydration 1

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

• Give oral dexamethasone 0.15-0.60 mg/kg immediately 1, 2
• Add nebulized epinephrine 0.5 mL/kg of 1:1000 solution (or 4 mL of 1:1000 undiluted for severe cases) 1, 3
• Administer oxygen to maintain saturation ≥94% via nasal cannulae, head box, or face mask 1
• Monitor for at least 2 hours after the last epinephrine dose due to short-lived effect (1-2 hours) and risk of rebound symptoms 1, 2

Hospitalization Criteria

Consider admission when: 1

• Three or more doses of racemic epinephrine are required
• Oxygen saturation <92-94% despite supplemental oxygen
• Age <18 months with moderate-to-severe symptoms
• Respiratory rate >70 breaths/min
• Family unable to provide appropriate observation or supervision

Recent guidelines demonstrate that limiting admission until 3 doses of epinephrine are needed reduces hospitalization rates by 37% without increasing adverse outcomes. 1

Critical Pitfalls to Avoid

• Never discharge within 2 hours of nebulized epinephrine administration due to rebound risk 1, 4
• Never use nebulized epinephrine in outpatient settings where immediate return is not feasible 1
• Never perform blind finger sweeps if foreign body aspiration is suspected, as this may push objects deeper 1
• Avoid agitating the child during examination, as distress can worsen airway obstruction 3

Supportive Care Measures

• Position the child comfortably (neutral head position with roll under shoulders for children <2 years optimizes airway patency) 1
• Maintain adequate hydration and monitor for dehydration 1
• Use antipyretics for fever control and comfort 1
• Humidified or cold air provides no proven benefit and is not recommended 1, 5
• Minimal handling may reduce metabolic and oxygen requirements 1

Discharge Instructions

If discharged home after observation: 1

• Review by primary care provider if deteriorating or not improving after 48 hours
• Educate family on managing fever, preventing dehydration, and recognizing signs of deterioration
• Ensure family is reliable and able to monitor and return if worsening

Special Considerations for Recurrent Croup

If the child has had multiple episodes of croup, consider: 1

• Asthma as differential diagnosis (especially if cough worsens at night, triggered by exercise/irritants, or family history of atopy)
• Anatomic abnormalities requiring flexible bronchoscopy if symptoms are severe, persistent, or atypical
• Prophylactic inhaled corticosteroids may benefit children with recurrent episodes

Antibiotics have no role in uncomplicated viral croup and should not be prescribed. 6, 4