Treatment of Croup in Pediatric Patients
Oral dexamethasone 0.15-0.6 mg/kg (maximum 10-12 mg) as a single dose is the first-line treatment for all children with croup, regardless of severity, with nebulized epinephrine reserved for moderate to severe cases. 1, 2, 3
Initial Assessment
When evaluating a child with suspected croup, immediately assess:
- Severity indicators: stridor at rest, respiratory rate, use of accessory muscles, oxygen saturation, and ability to speak/cry normally 3
- Life-threatening signs: silent chest, cyanosis, fatigue/exhaustion, or poor respiratory effort 3
- Differential diagnoses to exclude: bacterial tracheitis, epiglottitis, foreign body aspiration, retropharyngeal or peritonsillar abscess 3, 4
Radiographic studies are generally unnecessary and should be avoided unless there is concern for an alternative diagnosis. 1, 3
Treatment Algorithm Based on Severity
Mild Croup
- Administer oral dexamethasone 0.15-0.6 mg/kg (maximum 10-12 mg) as a single dose 1, 2, 4
- This is sufficient treatment for mild cases 1
- The lower dose of 0.15 mg/kg appears equally effective as 0.60 mg/kg 5
Moderate to Severe Croup (stridor at rest or significant respiratory distress)
- Administer oral dexamethasone 0.15-0.6 mg/kg (maximum 10-12 mg) as a single dose 1, 2
- Add nebulized epinephrine 0.5 mL/kg of 1:1000 solution (maximum 5 mL) 1, 3, 6
- Mandatory observation for at least 2 hours after the last dose of epinephrine to monitor for rebound symptoms 2, 3
- The effect of nebulized epinephrine is short-lived, lasting only 1-2 hours 3, 6
Alternative Corticosteroid Options
- Nebulized budesonide 2 mg is equally effective as oral dexamethasone when oral administration is not feasible 1, 6
- Prednisolone 1-2 mg/kg (maximum 40 mg) if dexamethasone is unavailable 3
Supportive Care
- Administer oxygen via nasal cannulae, head box, or face mask to maintain oxygen saturation above 92-94% 1, 3
- Antipyretics can be used for comfort 1, 3
- Minimal handling may reduce metabolic and oxygen requirements 1, 3
- Monitor oxygen saturation at least every 4 hours for patients on oxygen therapy 3
Hospitalization Criteria
Consider hospitalization when:
- Need for ≥3 doses of nebulized epinephrine (the "3 is the new 2" approach) 7, 1, 3
- Oxygen saturation <92% 1, 3
- Age <18 months 1, 3
- Respiratory rate >70 breaths/min 1, 3
- Persistent difficulty in breathing 1, 3
The updated criterion of 3 doses (rather than the traditional 2 doses) reduces hospitalization rates by 37% without increasing revisits or readmissions. 7, 1
Discharge Criteria
Patients may be discharged when:
- Resolution of stridor at rest 1
- Minimal or no respiratory distress 1
- Adequate oral intake 1
- Parents able to recognize worsening symptoms and return if needed 1, 3
- At least 2 hours have passed since the last dose of nebulized epinephrine 2, 3
Families should be instructed to return if the child deteriorates or does not improve after 48 hours. 1, 3
Critical Pitfalls to Avoid
- Never discharge a patient within 2 hours of nebulized epinephrine administration due to risk of rebound symptoms 2, 3
- Never use nebulized epinephrine in outpatient settings where immediate return is not feasible 2, 3
- Never admit after only 1-2 doses of epinephrine when a third dose could be safely given in the emergency department with appropriate observation 1, 2
- Never use antibiotics routinely, as croup is viral in etiology 1, 2
- Never rely on cool mist therapy or humidified air as definitive treatment, as it lacks evidence of benefit 3, 6
- Never perform blind finger sweeps if foreign body aspiration is suspected, as this may push objects further into the pharynx 3