What is the recommended treatment for a child presenting with croup?

Management of Croup in Children

Immediate Treatment: Corticosteroids for All Cases

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. 1, 2

• Oral dexamethasone begins working within 30 minutes, much earlier than previously thought, with statistically significant improvement by 30 minutes and continued benefit thereafter 3
• Both 0.15 mg/kg and 0.6 mg/kg doses are equally effective for moderate to severe croup, with no difference in croup scores or time to improvement 4
• The lower dose (0.15 mg/kg) is preferred to minimize potential side effects while maintaining efficacy 3, 4
• If oral administration is not feasible, nebulized budesonide 2 mg (or 500-2000 µg) is equally effective as an alternative 2, 5

Severity-Based Treatment Algorithm

Mild Croup (No Stridor at Rest)

• Administer oral dexamethasone 0.15-0.6 mg/kg as a single dose 1, 2
• Observe for 2-3 hours to ensure symptoms are improving 5
• No nebulized treatments needed 5

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

• Immediately give oral dexamethasone 0.15-0.6 mg/kg 1, 2
• Add nebulized epinephrine 0.5 ml/kg of 1:1000 solution (maximum 5 ml) 1, 2, 5
• Administer oxygen to maintain saturation ≥94% 1, 2
• Critical: Observe 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, 5

Hospitalization Criteria: The "3 is the New 2" Rule

Consider hospital admission only after 3 doses of nebulized epinephrine are required, not the traditional 2 doses. 1, 2, 5

• This updated approach reduces hospitalization rates by 37% without increasing revisits or readmissions 1, 2
• Additional admission criteria include: 1, 2
  • Oxygen saturation <92%
  • Age <18 months
  • Respiratory rate >70 breaths/min
  • Persistent difficulty breathing despite treatment

Critical Pitfalls to Avoid

Never discharge a patient within 2 hours of nebulized epinephrine administration due to the high risk of rebound airway obstruction 1, 2, 5, 6

• Never use nebulized epinephrine in outpatient settings where immediate return is not feasible, as rebound symptoms can occur after the 1-2 hour effect wears off 1, 2, 5
• Do not admit patients after only 1-2 doses of epinephrine when they could safely receive a third dose in the emergency department with appropriate observation 2
• Do not fail to administer corticosteroids in mild cases—all severities benefit from steroid treatment 2, 5
• Do not use humidified or cold air therapy, as current evidence shows no benefit 1
• Do not use antibiotics routinely, as croup is viral in etiology 2

Discharge Criteria

Children may be discharged home when: 2, 5

• Stridor at rest has resolved
• Minimal or no respiratory distress present
• Adequate oral intake maintained
• Parents can recognize worsening symptoms and return if needed
• At least 2 hours have passed since last epinephrine dose (if given)

Follow-Up and Parent Education

• Instruct parents to return immediately if the child develops worsening stridor, increased work of breathing, or inability to drink 1, 2
• If discharged home, the child should be reviewed by a physician if deteriorating or not improving after 48 hours 1, 2
• Antipyretics can be used for comfort 1, 2
• Ensure adequate hydration 1

Differential Diagnoses to Consider

If the child fails to respond to standard treatment, consider: 1

• Bacterial tracheitis
• Foreign body aspiration (never perform blind finger sweeps)
• Epiglottitis
• Retropharyngeal or peritonsillar abscess

Flexible bronchoscopy should be performed in cases of severe or persistent symptoms not responding to standard treatment, associated hoarseness, oxygen desaturation, or atypical presentation 1