What is the initial treatment for a toddler with croup?

Treatment of Croup in a Toddler

Administer oral dexamethasone 0.15-0.6 mg/kg (maximum 10-12 mg) as a single dose immediately for all toddlers with croup, regardless of severity. 1, 2

Initial Assessment

Evaluate the toddler for severity indicators to guide treatment escalation:

• Mild croup: Barking cough with minimal or no stridor at rest, no respiratory distress 1
• Moderate to severe croup: Stridor at rest, use of accessory muscles, increased respiratory rate, agitation (may indicate hypoxia) 2
• Life-threatening signs: Silent chest, cyanosis, fatigue/exhaustion, poor respiratory effort—these require immediate intervention 2

Radiographic studies are unnecessary unless you suspect an alternative diagnosis such as bacterial tracheitis, foreign body aspiration, or retropharyngeal abscess 1, 2

Treatment Algorithm by Severity

For Mild Croup

• Oral dexamethasone alone is sufficient 1
• Observe for 2-3 hours to ensure symptoms are improving 3
• Antipyretics can be used for comfort 2

For Moderate to Severe Croup

• Add nebulized epinephrine (0.5 ml/kg of 1:1000 solution, maximum 5 ml) to the oral dexamethasone 1, 2
• The effect of nebulized epinephrine is short-lived, lasting only 1-2 hours 2, 3
• Observe for at least 2 hours after each dose of nebulized epinephrine to assess for rebound symptoms 2, 3
• If oxygen saturation is <94%, administer supplemental oxygen via nasal cannula, head box, or face mask 2

Alternative Corticosteroid Option

• Nebulized budesonide 2 mg is equally effective as oral dexamethasone when oral administration is not feasible 1, 3

Multiple Epinephrine Doses and Hospitalization

The American Academy of Pediatrics now recommends considering hospitalization after 3 doses of nebulized epinephrine rather than the traditional 2 doses, which reduces hospitalization rates by 37% without increasing revisits or readmissions 1, 2

• Restart the 2-hour observation clock after each epinephrine dose 2
• If a second dose is needed, continue observation 2
• Consider admission after the third dose of nebulized epinephrine 1, 2, 3

Additional Hospitalization Criteria

• Oxygen saturation <92% 1, 2
• Age <18 months (high-risk group) 1, 2
• Respiratory rate >70 breaths/min 1
• Persistent difficulty breathing despite treatment 1

Critical Pitfalls to Avoid

• Never discharge a patient within 2 hours of nebulized epinephrine administration due to risk of rebound symptoms 1, 2, 3
• Never use nebulized epinephrine in outpatient settings where immediate return is not feasible 1, 2, 3
• 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 1
• Do not fail to administer corticosteroids in mild cases—all cases benefit from steroids 1, 3
• Do not use antibiotics routinely, as croup is viral in etiology 1
• Do not rely on cold air or humidified air treatments, which lack evidence of benefit 2

Discharge Criteria

The toddler can be safely discharged when:

• Stridor at rest has resolved 1, 3
• Minimal or no respiratory distress present 1, 3
• Adequate oral intake maintained 1, 3
• Parents can recognize worsening symptoms and know to return if needed 1, 3
• At least 2 hours have passed since the last epinephrine dose without rebound 2, 3

Follow-Up Instructions

• If discharged home, the child should be reviewed by a general practitioner if deteriorating or not improving after 48 hours 1, 2
• Provide clear return precautions to parents regarding signs of worsening respiratory distress 1
• Educate families on managing fever, preventing dehydration, and identifying signs of deterioration 2