First-Line Treatment for Pediatric Croup
Oral dexamethasone 0.15-0.6 mg/kg (maximum 10-12 mg) as a single dose is the first-line treatment for all pediatric patients with croup, regardless of severity. 1, 2, 3, 4
Treatment Algorithm Based on Severity
Mild Croup
- Administer oral dexamethasone alone at 0.15-0.6 mg/kg (maximum 10-12 mg) as a single dose 1, 2, 3
- Alternative: Prednisolone 1.0-2.0 mg/kg (maximum 40 mg) if dexamethasone unavailable 2, 5, 6
- Review patient in 1 hour after administration 6
Moderate to Severe Croup
- Give oral dexamethasone PLUS nebulized epinephrine 1, 2, 3, 4
- Nebulized epinephrine dose: 0.5 mL/kg of 1:1000 solution (maximum 5 mL) 1, 2
- Alternative for severe cases: 4 mL of undiluted adrenaline 1:1000 via nebulizer 6
- Observe for minimum 2 hours after each epinephrine dose due to short-lived effect (1-2 hours) and risk of rebound symptoms 1, 2, 7, 8
Alternative Corticosteroid Route
- Nebulized budesonide 2 mg is equally effective as oral dexamethasone when oral administration is not feasible (e.g., vomiting) 1, 8
Critical Hospitalization Criteria
Consider admission after 3 doses of nebulized epinephrine (not the traditional 2 doses), which reduces hospitalization rates by 37% without increasing revisits or readmissions 1, 9, 2
Additional admission indicators include:
- Oxygen saturation <92% 1, 2
- Age <18 months with severe symptoms 1, 2
- Respiratory rate >70 breaths/min 1, 2
- Persistent difficulty breathing despite treatment 1, 2
Supportive Care Measures
- Administer oxygen to maintain saturation ≥94% via nasal cannulae, head box, or face mask 1, 2
- Use antipyretics for comfort 1, 2
- Minimize handling to reduce metabolic and oxygen requirements 1, 2
- Monitor oxygen saturation at least every 4 hours for patients on oxygen therapy 2
Critical Pitfalls to Avoid
- Never discharge within 2 hours of nebulized epinephrine administration due to rebound risk 1, 2, 7
- Do not use nebulized epinephrine in outpatient settings where immediate return is not feasible 1, 9, 2
- Do not admit after only 1-2 doses of epinephrine when a third dose could be safely administered in the ED with appropriate observation 1
- Avoid routine antibiotics—croup is viral in etiology 1
- Do not rely on humidified or cold air treatments, which lack evidence of benefit 1, 2
- Radiographic studies are generally unnecessary and should be avoided unless alternative diagnosis suspected 1, 2
Discharge Criteria
Patients may be discharged home 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
- Review by general practitioner if deteriorating or not improving after 48 hours 1, 2
When to Consider Alternative Diagnoses
Failure to respond to standard treatment warrants investigation for:
- Bacterial tracheitis 9, 2, 3
- Foreign body aspiration 9, 2, 3
- Epiglottitis 2, 3
- Retropharyngeal or peritonsillar abscess 2, 3
Direct visualization by laryngoscopy is the most important investigation when standard treatment fails 9