What is the initial treatment for a pediatric patient with croup in an outpatient setting?

Outpatient Treatment of Croup

Administer oral dexamethasone 0.15-0.6 mg/kg (maximum 10-12 mg) as a single dose to all children with croup, regardless of severity, and reserve nebulized epinephrine for moderate-to-severe cases only in settings where 2-hour observation is feasible. 1, 2

Initial Assessment

Evaluate severity by assessing for:

• Stridor at rest (indicates moderate-to-severe disease) 1
• Respiratory distress signs: retractions, nasal flaring, increased work of breathing 1
• Oxygen saturation (maintain >94%) 1
• Ability to speak/cry normally and overall appearance 1

Critical pitfall: Do not obtain radiographs unless considering alternative diagnoses such as foreign body aspiration, bacterial tracheitis, or retropharyngeal abscess. 1, 2

Treatment Algorithm

Mild Croup (No Stridor at Rest)

• Oral dexamethasone 0.15-0.6 mg/kg (maximum 10-12 mg) as a single dose 1, 2
• Alternative: Prednisolone 1-2 mg/kg (maximum 40 mg) if dexamethasone unavailable 1
• Discharge home with return precautions 2

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
• Add nebulized epinephrine 0.5 ml/kg of 1:1000 solution (maximum 5 ml) 1, 2
• Mandatory 2-hour observation period after each epinephrine dose 1, 2
• If symptoms recur, administer second dose of nebulized epinephrine and restart 2-hour observation clock 1

Critical warning: Never use nebulized epinephrine in true outpatient settings where immediate return is not feasible, as rebound symptoms occur after 1-2 hours. 1, 2

Disposition Criteria

Safe for Discharge After Observation

• Resolution of stridor at rest 2
• Minimal or no respiratory distress 2
• Adequate oral intake 2
• Reliable family able to monitor and return if worsening 1

Requires Emergency Department Transfer or Admission

• Need for ≥3 doses of nebulized epinephrine (updated criterion reduces unnecessary admissions by 37%) 1, 2
• 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 2

Supportive Care

• Antipyretics for comfort and fever control 1
• Adequate hydration and monitoring for dehydration 1
• Minimal handling to reduce oxygen requirements 1, 2
• Oxygen supplementation if saturation <94% 1, 2

Important: Cold air, humidified air, and mist therapy provide no proven benefit and should not be recommended. 1, 2

Follow-Up Instructions

• Review by primary care provider if deteriorating or not improving after 48 hours 1, 2
• Return immediately for: worsening stridor, increased work of breathing, inability to drink, cyanosis, or exhaustion 2
• Do not prescribe antibiotics as croup is viral in etiology 2

Alternative Corticosteroid Options

• Nebulized budesonide 2 mg is equally effective when oral administration is not feasible (vomiting, severe distress) 2, 3
• Intramuscular dexamethasone 0.6 mg/kg if oral route impossible 4