What is the initial management of croup in a pediatric patient?

Initial Management of Croup in Pediatric Patients

Administer oral dexamethasone 0.15-0.6 mg/kg (maximum 10-12 mg) as a single dose immediately to all children with croup, regardless of severity, and add nebulized epinephrine only for moderate to severe cases with stridor at rest or significant respiratory distress. 1

First-Line Treatment: Corticosteroids for All Cases

• Oral dexamethasone is the gold standard for all croup cases, mild through severe. 1
• Give a single dose of 0.15-0.6 mg/kg (maximum 10-12 mg) orally. 2, 1
• For mild croup (no stridor at rest, minimal respiratory distress), dexamethasone alone is sufficient—do not add epinephrine. 2, 1
• The American Academy of Pediatrics recommends this approach for all severity levels. 1, 3

When to Add Nebulized Epinephrine

Reserve nebulized epinephrine exclusively for moderate to severe croup with stridor at rest or significant respiratory distress. 1

• Dose: 0.5 mL/kg of 1:1000 solution (maximum 5 mL) via nebulizer. 2, 3
• The effect is short-lived, lasting only 1-2 hours, so close monitoring is essential. 3
• Mandatory 2-hour observation period after each dose of epinephrine to monitor for rebound symptoms. 1, 3
• Never discharge within 2 hours of epinephrine administration. 1

Observation and Disposition Algorithm

Consider hospitalization only after 3 doses of nebulized epinephrine—not the traditional 2 doses. 2, 1

• The "3 is the new 2" approach reduces hospitalization rates by 37% without increasing revisits or readmissions. 2, 3
• Restart the 2-hour observation clock after each epinephrine dose. 3
• If a third dose is needed, strongly consider admission rather than extended observation. 3

Additional Hospitalization Criteria:

• Oxygen saturation <92% 2, 3
• Age <18 months with severe symptoms 2, 3
• Respiratory rate >70 breaths/min 2
• Persistent respiratory distress despite treatment 2

Supportive Care Measures

• Administer supplemental oxygen via nasal cannula, head box, or face mask to maintain oxygen saturation ≥94%. 3
• Use antipyretics for comfort and to help with coughing. 3
• Minimize handling to reduce metabolic and oxygen requirements. 3
• Avoid humidified or cold air therapy—current evidence shows no benefit. 3

Discharge Criteria

Discharge is appropriate when all of the following are met: 2

• Resolution of stridor at rest 2
• Minimal or no respiratory distress 2
• Adequate oral intake 2
• Parents can recognize worsening symptoms and know to return if needed 2, 3
• At least 2 hours have passed since the last epinephrine dose (if given) 1, 3

Instruct families to follow up with their primary care provider if symptoms worsen or fail to improve within 48 hours. 3

Critical Pitfalls to Avoid

• Never use nebulized epinephrine in outpatient settings where immediate return is not feasible—rebound symptoms can occur after the 1-2 hour effect wears off. 2, 1
• Never admit after only 1-2 doses of epinephrine when a third dose could be safely given in the emergency department—this unnecessarily increases hospitalization rates. 2, 1
• Never fail to administer corticosteroids in mild cases—even mild croup benefits from dexamethasone. 2
• Never use antibiotics routinely, as croup is viral in etiology. 1
• Never rely on cool mist or humidified air as definitive treatment—it lacks evidence of benefit. 1, 3
• Never discharge patients too early after nebulized epinephrine (before the 2-hour observation period). 2, 1

Diagnostic Considerations

• Diagnosis is clinical—radiographic studies are generally unnecessary and should be avoided unless there is concern for an alternative diagnosis. 2, 3
• Consider alternative diagnoses if the patient fails to respond to standard treatment: bacterial tracheitis, epiglottitis, foreign body aspiration, retropharyngeal or peritonsillar abscess. 3
• Never perform blind finger sweeps in suspected foreign body aspiration—this may push objects further into the pharynx. 3