What is the initial management for a 12 to 16 month old child presenting with croup?

Management of Croup in a 12 to 16 Month Old

Administer oral dexamethasone 0.15-0.6 mg/kg (maximum 10-12 mg) as a single dose immediately for 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, 2

Initial Assessment

Evaluate the child for severity indicators:

• Stridor at rest (indicates moderate to severe disease) 2
• Respiratory rate (>70 breaths/min warrants admission consideration) 2
• Use of accessory muscles 2
• Oxygen saturation (<92% indicates need for hospitalization) 1, 2
• Ability to cry normally and presence of cyanosis or fatigue (life-threatening signs) 2

Avoid radiographic studies unless concerned about alternative diagnoses such as bacterial tracheitis, foreign body aspiration, or retropharyngeal abscess. 1, 2

Treatment Algorithm Based on Severity

Mild Croup (No Stridor at Rest)

• Oral dexamethasone 0.15-0.6 mg/kg (maximum 10-12 mg) as a single dose 1, 2, 3
• Observe for 2-3 hours to ensure symptoms are improving 4
• No nebulized epinephrine needed 1

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

• Oral dexamethasone 0.15-0.6 mg/kg (maximum 10-12 mg) as a single dose 1, 2, 3
• Add nebulized epinephrine 0.5 ml/kg of 1:1000 solution (maximum 5 ml) 1, 2, 4
• Observe for at least 2 hours after each epinephrine dose to monitor for rebound symptoms 1, 2, 4
• Administer oxygen to maintain saturation ≥94% if needed 2

Alternative corticosteroid option: Nebulized budesonide 2 mg can be used if oral administration is not feasible and is equally effective as oral dexamethasone. 1, 4

Hospitalization Criteria

This age group (12-16 months) requires special attention as age <18 months is itself a risk factor for admission. 1, 2

Admit if any of the following are present:

• Need for ≥3 doses of nebulized epinephrine (the "3 is the new 2" approach reduces unnecessary admissions by 37% without increasing revisits) 5, 1, 2, 4
• Oxygen saturation <92% 1, 2
• Respiratory rate >70 breaths/min 1, 2
• Persistent respiratory distress despite treatment 1

Critical Management Pitfalls to Avoid

Never discharge within 2 hours of nebulized epinephrine administration due to the short-lived effect (1-2 hours) and risk of rebound symptoms. 1, 2, 4, 6, 7

Do not use nebulized epinephrine in outpatient settings where immediate return is not feasible, as rebound symptoms can occur after the medication wears off. 1, 2, 4

Do not admit after only 1-2 doses of epinephrine when a third dose could be safely administered in the emergency department with appropriate observation—this prevents unnecessary hospitalizations. 5, 1, 2

Always administer corticosteroids even in mild cases—failing to do so is a common error. 1

Avoid humidified air or cold air treatments as they lack evidence of benefit. 1, 2

Do not use antibiotics routinely as croup is viral in etiology. 1, 3

Discharge Criteria

The child can be safely discharged home if:

• Resolution of stridor at rest 1, 4
• Minimal or no respiratory distress 1, 4
• Adequate oral intake 1, 4
• Parents can recognize worsening symptoms and have reliable access to return if needed 1, 2, 4

Home Care Instructions

Provide clear return precautions to parents:

• Return immediately if stridor worsens, breathing becomes more difficult, child appears exhausted, or develops cyanosis 1
• Follow up with primary care if not improving after 48 hours 2
• Use antipyretics for comfort 2
• Ensure adequate hydration 2, 7
• Minimize handling to reduce metabolic and oxygen requirements 2