What is the appropriate management for a previously healthy child aged 6 months to 5 years presenting with a barking cough and inspiratory stridor consistent with croup?

Croup Management

Immediate Treatment: Corticosteroids for All Cases

All children with croup should receive a single dose of oral dexamethasone 0.15-0.6 mg/kg (maximum 10-12 mg) regardless of severity. 1, 2 This is the gold standard first-line treatment that reduces symptom severity, return visits, emergency department visits, and hospitalizations. 3, 4

• Oral dexamethasone is preferred over intramuscular or nebulized budesonide due to ease of administration and equivalent efficacy. 3, 4
• If the child cannot tolerate oral medication due to vomiting, intramuscular dexamethasone 0.6 mg/kg is an acceptable alternative. 5, 6
• The onset of action is approximately 6 hours, so additional interventions may be needed for immediate symptom relief in severe cases. 5

Add Nebulized Epinephrine for Moderate to Severe Croup

Reserve nebulized epinephrine for children with stridor at rest or significant respiratory distress. 1, 2

• Administer 0.5 mL/kg of 1:1000 epinephrine solution (maximum 5 mL) via nebulizer. 1, 2
• Both racemic epinephrine and L-epinephrine are equally effective. 7
• The effect is rapid but short-lived, lasting only 1-2 hours. 1, 2
• Mandatory observation for at least 2 hours after the last epinephrine dose is required to monitor for rebound symptoms. 1, 2
• Never discharge a patient within 2 hours of epinephrine administration. 1, 2
• Never use epinephrine in outpatient settings where immediate return is not feasible. 1

Supportive Care

Administer supplemental oxygen to maintain oxygen saturation ≥94%. 1

• Use nasal cannulae, head box, or face mask as appropriate. 8, 1
• Agitation may indicate hypoxemia rather than anxiety, requiring oxygen therapy. 8, 1
• Monitor oxygen saturation at least every 4 hours for patients on oxygen therapy. 8, 1

Minimize handling to reduce metabolic and oxygen requirements in severely ill children. 8, 1

Maintain adequate hydration. 5, 6

• If intravenous fluids are needed, administer at 80% basal levels and monitor serum electrolytes. 8
• Avoid nasogastric tubes in severely ill children as they may compromise breathing. 8

What NOT to Do

Do not use the following interventions as they provide no benefit and may cause harm:

• Over-the-counter cough or cold medications. 9
• Antihistamines or decongestants. 9, 6
• Antibiotics (croup is viral). 2, 6
• Chest physiotherapy. 8, 1
• Cool mist therapy as definitive treatment (lacks evidence of benefit). 1, 2

Hospitalization Criteria

Admit to the hospital if any of the following are present: 1, 2

• Three or more doses of nebulized epinephrine required. 1, 2
• Oxygen saturation <92%. 1, 2
• Age <18 months with severe symptoms. 1, 2
• Respiratory rate >70 breaths/min. 1, 2
• Persistent respiratory distress despite treatment. 1, 2
• Family unable to provide appropriate observation or supervision. 8, 1

Recent evidence shows that limiting admission until 3 doses of epinephrine are needed reduces hospitalization rates by 37% without increasing revisits or readmissions. 1

Discharge Criteria

Children can be safely discharged if: 8, 1

• At least 2 hours have passed since the last epinephrine dose with no rebound symptoms. 1, 2
• Oxygen saturation >92% on room air. 8
• No respiratory distress. 7
• Respiratory rate <50 breaths/min (or <40 breaths/min in older children). 8
• Family is reliable and able to monitor and return if worsening. 1
• Access to follow-up and emergency care is available. 7

Follow-Up Instructions

Families should be instructed to: 8, 1

• Return immediately if respiratory distress worsens, stridor increases, or the child cannot maintain hydration. 8
• Follow up with their primary care provider if not improving after 48 hours. 8
• Manage fever with antipyretics for comfort. 8
• Ensure adequate fluid intake to prevent dehydration. 8

Differential Diagnoses to Consider

If the child fails to respond to standard treatment or has atypical features, consider: 1

• Bacterial tracheitis (high fever, toxic appearance). 1
• Foreign body aspiration (sudden onset without prodrome, unilateral findings). 1
• Epiglottitis (rare in vaccinated populations, drooling, toxic appearance). 4
• Retropharyngeal or peritonsillar abscess. 1

Radiographic studies are generally unnecessary and should be avoided unless there is concern for an alternative diagnosis. 1