How should croup be managed in a 4‑year‑old child?

Management of Croup in a 4-Year-Old Child

All children with croup, regardless of severity, should receive a single dose of oral dexamethasone 0.15-0.6 mg/kg (maximum 10-12 mg), with nebulized epinephrine reserved for moderate to severe cases presenting with stridor at rest or significant respiratory distress. 1, 2

Initial Assessment

Evaluate the child immediately for severity indicators:

• Ability to speak or cry normally 1
• Respiratory rate and heart rate 1
• Presence of stridor at rest (indicates moderate to severe disease) 1, 3
• Use of accessory muscles, tracheal tug, or chest wall retractions 1
• Oxygen saturation (maintain ≥94%) 1, 2
• Signs of exhaustion, cyanosis, or silent chest (life-threatening indicators) 1

The diagnosis is clinical—radiographic studies are unnecessary and should be avoided unless you suspect an alternative diagnosis such as bacterial tracheitis, foreign body aspiration, epiglottitis, or retropharyngeal abscess. 1, 2, 3

Treatment Algorithm

For All Cases (Mild, Moderate, and Severe):

Administer oral dexamethasone 0.15-0.6 mg/kg as a single dose (maximum 10-12 mg). 1, 2, 3 This is the cornerstone of croup management and reduces symptoms, return visits, and hospitalization length across all severity levels. 4

• Alternative if oral route not feasible: Nebulized budesonide 2 mg is equally effective 2
• Prednisolone 1-2 mg/kg (maximum 40 mg) can substitute if dexamethasone is unavailable 1

For Moderate to Severe Cases (Stridor at Rest or Respiratory Distress):

Add nebulized epinephrine 0.5 mL/kg of 1:1000 solution (maximum 5 mL) diluted in saline. 1, 2, 5

• The effect is rapid but temporary, lasting only 1-2 hours 1, 2
• Observe the child for at least 2 hours after each epinephrine dose to monitor for rebound symptoms 1, 2, 6
• If a second dose is needed, restart the 2-hour observation clock 1

Supportive Care:

• Administer supplemental oxygen to maintain saturation ≥94% via nasal cannula, face mask, or head box 1, 2
• Use antipyretics for comfort (not solely to reduce fever) 2
• Minimize handling to reduce metabolic demands 2
• Ensure adequate hydration 2

Hospitalization Criteria

Consider admission if the child requires ≥3 doses of nebulized epinephrine. 1, 2 This updated threshold (rather than the traditional 2 doses) reduces unnecessary hospitalizations by 37% without increasing adverse outcomes. 1, 2

Additional admission criteria include:

• Oxygen saturation <92% 2
• Age <18 months with severe symptoms 1, 2
• Respiratory rate >70 breaths/min 2
• Persistent difficulty breathing despite treatment 2
• Inability of family to provide appropriate observation at home 1

Discharge Criteria and Home Care Instructions

The child can be discharged home if:

• Stridor at rest has resolved 2
• Minimal or no respiratory distress 2
• Adequate oral intake 2
• At least 2 hours have passed since the last epinephrine dose without rebound symptoms 1, 2
• Parents can recognize worsening symptoms and return if needed 2

Provide clear return precautions:

• Extreme fatigue, lethargy, or difficulty staying awake requires immediate medical attention 2
• Return if symptoms worsen or fail to improve within 48 hours 2, 7
• Reassure parents that the barking cough sounds frightening but the airway remains open in most cases 2

Critical Pitfalls to Avoid

• Never discharge within 2 hours of nebulized epinephrine administration due to rebound risk 1, 2
• Never use nebulized epinephrine in outpatient settings where immediate return is not feasible 1
• Do not admit after only 1-2 doses of epinephrine when a third dose could be safely administered in the emergency department 2
• Do not give over-the-counter cough or cold medications—they provide no benefit and can cause harm 2, 7
• Do not prescribe antibiotics—croup is viral and antibiotics are ineffective 2
• Avoid codeine-containing medications due to respiratory depression risk 2
• Do not rely on humidified or cold air treatments—evidence does not support their use 1, 2

Special Considerations

At 4 years of age, this child is at the upper end of the typical croup age range (6 months to 3 years). 4 If croup episodes are recurrent, consider asthma as a differential diagnosis, particularly if there is nocturnal cough worsening, exercise triggers, or family history of atopy. 1

Most children with croup recover completely within 2 days without long-term effects. 3, 2 Less than 3% of hospitalized patients require intubation. 3