What is the initial treatment for a child presenting with croup?

Initial Treatment for Croup in Children

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 add nebulized epinephrine (0.5 ml/kg of 1:1000 solution, maximum 5 ml) only for moderate to severe cases with stridor at rest or respiratory distress. 1, 2

Immediate Assessment

Upon presentation, rapidly assess for:

• Severity indicators: stridor at rest, use of accessory muscles, respiratory rate, oxygen saturation, and ability to speak/cry normally 1
• Life-threatening signs: silent chest, cyanosis, fatigue/exhaustion, or poor respiratory effort—these require immediate intervention 1, 3
• Alternative diagnoses to exclude: bacterial tracheitis, foreign body aspiration, epiglottitis, retropharyngeal abscess 1, 4, 5

Treatment Algorithm by 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, 4, 5
• Observe for 2-3 hours to ensure symptoms are improving 3
• No nebulized treatments needed 3

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

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

Alternative corticosteroid option: Nebulized budesonide 2 mg is equally effective as oral dexamethasone when oral administration is not feasible 3

Critical Management Considerations

Nebulized Epinephrine Warnings

• The effect lasts only 1-2 hours, requiring close monitoring for rebound symptoms 1, 2, 3
• Never discharge within 2 hours of epinephrine administration due to rebound risk 1, 2, 3
• Never use in outpatient settings where immediate return is not feasible 1, 2, 3
• Restart the 2-hour observation clock after each dose 1

Hospitalization Criteria

Admit if ANY of the following are present:

• ≥3 doses of nebulized epinephrine required (implementing "3 is the new 2" reduces admissions by 37% without increasing revisits) 1, 2, 3
• Oxygen saturation <92% 2
• Age <18 months with severe symptoms 1, 2
• Respiratory rate >70 breaths/min 2
• Persistent difficulty breathing despite treatment 2, 3

Supportive Care

• Maintain oxygen saturation ≥94% using nasal cannula, head box, or face mask 1, 2
• Use antipyretics for comfort 2
• Minimize handling to reduce metabolic demands 2
• Avoid chest physiotherapy—it provides no benefit 1

Common Pitfalls to Avoid

• Do NOT use humidified or cold air—current evidence shows no benefit 1, 4
• Do NOT give antibiotics—croup is viral 2, 4
• Do NOT give over-the-counter cough medicines—they have no proven benefit and can cause harm 2
• Do NOT discharge too early after epinephrine (before 2-hour observation) 1, 2, 3
• Do NOT admit after only 1-2 epinephrine doses when a third dose could be safely given in the ED 1, 3
• Do NOT obtain radiographs routinely—they are unnecessary unless alternative diagnoses are suspected 1, 2, 5

Discharge Criteria

Safe for discharge when ALL of the following are met:

• Resolution of stridor at rest 2, 3
• Minimal or no respiratory distress 2, 3
• Adequate oral intake 2, 3
• Parents able to recognize worsening symptoms and return if needed 1, 2, 3
• At least 2 hours have passed since last epinephrine dose (if given) 1, 2, 3

Instruct parents to return immediately for extreme fatigue, lethargy, difficulty staying awake, or worsening breathing 2. Follow-up with primary care if not improving after 48 hours 1, 2.