What is the appropriate management approach for a pediatric patient with croup?

Treatment of Croup in Pediatric Patients

Give oral dexamethasone 0.15-0.6 mg/kg (maximum 10-12 mg) as a single dose to every child with croup, regardless of severity, and add nebulized epinephrine only for moderate to severe cases with stridor at rest or significant respiratory distress. 1

Initial Assessment

Evaluate immediately for:

• Severity indicators: stridor at rest, respiratory rate, use of accessory muscles, oxygen saturation, and ability to speak/cry normally 2
• Life-threatening signs: silent chest, cyanosis, fatigue/exhaustion, or poor respiratory effort—these require immediate intervention 2
• Alternative diagnoses: bacterial tracheitis, epiglottitis, foreign body aspiration, retropharyngeal or peritonsillar abscess 2

Radiographic studies are unnecessary unless you suspect an alternative diagnosis 3, 2

Treatment Algorithm by Severity

Mild Croup

• Oral dexamethasone 0.15-0.6 mg/kg (maximum 10-12 mg) as a single dose is sufficient 3, 1
• This remains effective even at the lower end of the dosing range 1

Moderate to Severe Croup (stridor at rest or respiratory distress)

• Oral dexamethasone 0.15-0.6 mg/kg (maximum 10-12 mg) 1
• PLUS nebulized epinephrine 0.5 mL/kg of 1:1000 solution (maximum 5 mL) 3, 1
• Nebulized budesonide 2 mg is equally effective if oral administration is not feasible 3

Critical Observation Requirements

You must observe the patient for at least 2 hours after the last dose of nebulized epinephrine because the effect lasts only 1-2 hours and rebound symptoms can occur 1, 2. Never discharge within this 2-hour window 1. If a second dose is needed, restart the 2-hour observation clock 2.

Hospitalization Criteria

Admit if the patient meets any of these criteria:

• Requires ≥3 doses of nebulized epinephrine 3, 1, 2
• Oxygen saturation <92% 3, 2
• Age <18 months 3, 2
• Respiratory rate >70 breaths/min 3, 2
• Persistent respiratory distress 3

The "3 is the new 2" approach: Consider hospitalization after 3 doses of nebulized epinephrine rather than the traditional 2 doses, which reduces hospitalization rates by 37% without increasing revisits or readmissions 3, 2. Admitting after only 1-2 doses when a third could be safely given is a critical pitfall to avoid 3, 1.

Supportive Care

• Administer oxygen via nasal cannula, head box, or face mask to maintain oxygen saturation ≥94% 2
• Use antipyretics for comfort 2
• Minimize handling to reduce metabolic and oxygen requirements 2
• Ensure adequate hydration 2

Discharge Criteria

The patient can be discharged when:

• Stridor at rest has resolved 3
• Minimal or no respiratory distress 3
• Adequate oral intake 3
• Parents can recognize worsening symptoms and know to return if needed 3, 2
• At least 2 hours have passed since the last epinephrine dose 1, 2

Instruct parents to follow up with their general practitioner if the child deteriorates or does not improve after 48 hours 2.

Critical Pitfalls to Avoid

• Never use nebulized epinephrine in outpatient settings where immediate return is not feasible—rebound symptoms can occur after the 1-2 hour effect wears off 1, 2
• Never discharge within 2 hours of epinephrine administration 1
• Never admit after only 1-2 doses of epinephrine when a third dose could be safely given in the emergency department—this unnecessarily increases hospitalization rates 3, 1
• Never withhold corticosteroids in mild cases—they are indicated for all severities 3, 1
• Never use antibiotics routinely—croup is viral in etiology 3, 1
• Never rely on cool mist or humidified air therapy as definitive treatment—it lacks evidence of benefit 3, 1, 2