How should I manage a child aged 6 months to 5 years presenting with classic croup (barking cough, hoarse voice, inspiratory stridor)?

Management of Croup in Children Aged 6 Months to 5 Years

All children presenting with classic croup (barking cough, hoarse voice, inspiratory stridor) should receive a single dose of oral dexamethasone 0.15-0.60 mg/kg (maximum 10-12 mg) immediately, regardless of severity, with nebulized epinephrine reserved for moderate to severe cases showing stridor at rest or respiratory distress. 1, 2, 3

Initial Assessment

Evaluate the child immediately for severity indicators: 1

• Ability to speak/cry normally - loss indicates moderate-severe disease 1
• Stridor at rest - presence indicates at least moderate severity 1, 3
• Use of accessory muscles, tracheal tug, chest wall retractions - signs of respiratory distress 1
• Oxygen saturation - maintain ≥94% with supplemental oxygen if needed 1
• Life-threatening signs - silent chest, cyanosis, fatigue/exhaustion, poor respiratory effort require immediate intervention 1

Important caveat: Agitation may signal hypoxemia rather than anxiety, so assess oxygen saturation promptly. 1

Treatment Algorithm

All Severity Levels (Mild, Moderate, Severe)

Administer oral dexamethasone 0.15-0.60 mg/kg (maximum 10-12 mg) as a single dose immediately. 1, 2, 3 This is the cornerstone of treatment and should be given to every child with croup, even those with mild symptoms. 2, 4

• Oral route is preferred and equally effective as intramuscular 2, 4
• If oral administration fails, use intramuscular dexamethasone 0.6 mg/kg 5, 4
• Alternative: prednisolone 1-2 mg/kg (maximum 40 mg) if dexamethasone unavailable 1
• Onset of action is approximately 6 hours 5

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

Add nebulized epinephrine 0.5 mL/kg of 1:1000 solution (maximum 5 mL) diluted in 2.5 mL saline. 1, 6, 4

• Provides rapid but temporary relief lasting only 1-2 hours 1, 5
• Critical: Observe for at least 2 hours after each epinephrine dose to monitor for rebound symptoms 1, 5, 6
• Restart the 2-hour observation clock after each subsequent dose 1
• Never discharge within 2 hours of epinephrine administration 1

Oxygen Therapy

Administer supplemental oxygen to maintain saturation ≥94%. 1 Use simple oxygen masks or non-rebreathing masks as needed, applied directly to the face even when stridor is present. 1

Hospitalization Criteria

Admit to hospital if the child requires ≥3 doses of nebulized epinephrine. 1 This criterion has reduced unnecessary admissions by 37% without increasing revisits or readmissions. 1

Additional admission considerations: 1

• Age <18 months with severe symptoms
• Oxygen saturation <92%
• Respiratory rate >70 breaths/min (infants)
• Inability of family to provide appropriate observation or return if worsening

What NOT to Do

Do not give over-the-counter cough or cold medications - they provide no therapeutic benefit and may cause harm, with documented fatalities in young children. 7, 8, 6

Do not give antihistamines or decongestants - they are ineffective for croup and carry potential adverse effects. 8, 6

Do not use antibiotics routinely - croup is viral and antibiotics have no role unless bacterial tracheitis is suspected. 6, 3

Do not obtain radiographs routinely - diagnosis is clinical and imaging is unnecessary unless considering alternative diagnoses. 1, 3

Do not rely on humidified air as primary treatment - while maintaining 50% relative humidity may provide comfort, evidence for benefit is limited and it should not replace corticosteroids. 8, 5, 3

Differential Diagnoses to Consider

If the child fails to respond to standard treatment or presents atypically, consider: 1, 3

• Bacterial tracheitis - toxic appearance, high fever, purulent secretions 1, 3
• Foreign body aspiration - sudden onset without prodrome, unilateral findings 1, 3
• Epiglottitis - rare since Hib vaccination, but consider if toxic appearance with drooling 3
• Retropharyngeal or peritonsillar abscess - neck stiffness, difficulty swallowing 3

Never perform blind finger sweeps if foreign body suspected, as this may push objects further into the airway. 1

Discharge Instructions

For children discharged home after treatment: 1, 7

• Ensure family can provide appropriate observation and return if worsening
• Review signs requiring immediate return: increased work of breathing, inability to drink, cyanosis, lethargy
• Advise that symptoms typically resolve within 2 days, though cough may persist 3
• Schedule follow-up if not improving after 48 hours 1, 7
• Provide fever management guidance and ensure adequate hydration 7

Common Pitfalls

Discharging too soon after epinephrine - Always observe for at least 2 hours after the last dose to detect rebound symptoms. 1, 5

Using epinephrine in outpatient settings - Never give epinephrine to children who will be discharged immediately, as rebound symptoms can occur after the 1-2 hour effect wears off. 1

Underdosing dexamethasone - Lower doses (<0.15 mg/kg) have proven ineffective; use at least 0.15 mg/kg and up to 0.6 mg/kg for optimal effect. 5, 2

Prescribing unnecessary medications - Resist pressure to prescribe cough suppressants, antihistamines, or antibiotics, which are ineffective and potentially harmful. 7, 8, 6