Dexamethasone for Croup in a Two-Year-Old
Administer a single dose of oral dexamethasone 0.6 mg/kg (maximum 16 mg) immediately to your 2-year-old patient with croup. 1
Dosing and Administration
The standard dose is 0.6 mg/kg given as a single dose, with a maximum of 16 mg. 1 This recommendation comes from the American Academy of Pediatrics and represents the most widely accepted dosing strategy. 1
Route Selection
- Oral administration is the preferred route when the child can tolerate it, as it is equally effective as intramuscular injection while avoiding the pain of injection. 1
- All three routes (oral, IM, IV) demonstrate equal efficacy for croup treatment. 1
- Reserve intramuscular dexamethasone for patients who are vomiting or in severe respiratory distress and unable to tolerate oral medication. 2
Onset and Duration of Action
- Clinical benefit begins as early as 30 minutes after administration, much earlier than previously thought. 3
- The duration of action extends approximately 24-72 hours, providing sustained symptom relief. 1
- No tapering is required with the single-dose regimen, and it does not cause significant adrenal suppression. 1
Severity-Based Management Algorithm
Mild to Moderate Croup
- Administer dexamethasone 0.6 mg/kg orally (maximum 16 mg) as a single dose. 1
- Monitor for clinical improvement over the next 30-60 minutes. 3
Moderate to Severe Croup (stridor at rest, significant retractions, respiratory distress)
- Give dexamethasone 0.6 mg/kg immediately (oral, IM, or IV depending on severity). 1
- Add nebulized epinephrine 0.5 mL/kg of 1:1000 solution (maximum 5 mL) for significant respiratory distress while waiting for dexamethasone to take effect. 1, 4
- Understand that epinephrine provides rapid but temporary relief lasting only 1-2 hours. 5
- Observe the patient for at least 2 hours after the last dose of nebulized epinephrine to assess for rebound symptoms. 5
Severe Croup (prominent stridor, significant retractions, agitation)
- Administer dexamethasone 0.6 mg/kg plus nebulized epinephrine regardless of timing of initial dose. 1
- Consider hospital admission if three or more doses of racemic epinephrine are required. 5
Important Clinical Considerations
Lower Dose Evidence
While research demonstrates that 0.15 mg/kg dexamethasone is as effective as 0.3 or 0.6 mg/kg in relieving symptoms 6, 3, and the American Academy of Pediatrics suggests 0.15-0.60 mg/kg as acceptable 5, the standard recommended dose remains 0.6 mg/kg because it is universally accepted, well-tolerated, and eliminates any concern about underdosing. 1, 2
Common Pitfalls to Avoid
- Never discharge a patient within 2 hours of nebulized epinephrine administration due to risk of rebound symptoms. 5
- Do not use nebulized epinephrine in outpatient settings where immediate return is not feasible. 5
- Do not use nebulized corticosteroids from hand-held inhalers with spacers—they are ineffective for croup. 1
- Radiographic studies are generally unnecessary and should be avoided unless there is concern for an alternative diagnosis such as bacterial tracheitis or foreign body aspiration. 5
Alternative Diagnoses to Consider
If the patient fails to respond to standard treatment, consider:
- Bacterial tracheitis 5
- Foreign body aspiration 5
- Epiglottitis 5
- Retropharyngeal or peritonsillar abscess 5
Discharge Planning
- If discharged home after treatment, the child should be reviewed by a physician if deteriorating or not improving after 48 hours. 5
- Provide families with information on managing fever, preventing dehydration, and identifying signs of deterioration. 5
- Ensure the family is reliable and able to monitor the child and return if symptoms worsen. 5