What is the recommended treatment for croup in children aged 6 months to 5 years?

Treatment of Croup in Children

For children aged 6 months to 5 years with croup, administer a single dose of oral or intramuscular dexamethasone 0.6 mg/kg (or as low as 0.15 mg/kg for mild-moderate cases), and add nebulized epinephrine (racemic epinephrine 0.5 ml/kg of 1:1000 solution, maximum 5 mL) for moderate to severe cases with significant respiratory distress, observing the child for at least 2 hours after epinephrine administration to monitor for rebound symptoms. 1, 2

Corticosteroid Therapy (First-Line Treatment)

Dexamethasone is the mainstay of croup treatment and should be administered to all children with croup beyond the mildest presentations. 3

Dosing Options:

• Standard dose: 0.6 mg/kg (oral or intramuscular) as a single dose 1, 3, 4
• Lower effective doses: 0.15 mg/kg or 0.3 mg/kg are equally effective for mild-to-moderate croup 5, 6
• Route: Oral is preferred when tolerated; intramuscular if the child cannot take oral medication 3, 4

Important timing consideration: Dexamethasone onset of action is approximately 6 hours, so nebulized epinephrine may be needed for immediate symptom relief while waiting for steroid effect. 3

Alternative Corticosteroid:

• Prednisolone (1-2 mg/kg/day) can be used if dexamethasone is unavailable, though it requires multiple doses over 3 days and shows no superiority over single-dose dexamethasone. 7, 6

Nebulized Epinephrine (For Moderate to Severe Croup)

Add nebulized epinephrine for children with moderate to severe symptoms, including increased work of breathing, significant stridor at rest, or respiratory distress. 1, 2

Dosing and Administration:

• Racemic epinephrine: 0.5 ml/kg of 1:1000 solution (maximum 5 mL) diluted in 2.5 mL saline 1, 4
• Effect: Rapid onset (within 30 minutes) but short-lived (1-2 hours) 2
• Critical monitoring requirement: Observe for at least 2 hours after administration to watch for rebound airway obstruction 1, 3, 4

When to Use Epinephrine:

• To avoid intubation in severe cases 2
• To stabilize children prior to transfer to intensive care 2
• For stridor following intubation 2

Important caveat: Do not use epinephrine in children who are about to be discharged or on an outpatient basis due to the risk of rebound symptoms after the short-lived effect wears off. 2

Nebulized Budesonide (Alternative Option)

• Nebulized budesonide (500 µg) may reduce symptoms in the first 2 hours, though long-term data are limited. 2
• This is less commonly used than systemic dexamethasone in current practice. 2

Hospitalization Criteria

Children requiring two epinephrine treatments should be hospitalized. 4

Additional indications for hospital admission or return to emergency department:

• Increased work of breathing 1
• Inability to drink fluids 1
• Worsening stridor at rest 1
• Fatigue or decreased responsiveness 1

Life-threatening signs requiring immediate intensive care consideration:

• Cyanosis 1
• Decreased level of consciousness 1
• Fatigue/exhaustion 1
• Poor respiratory effort 1

Supportive Care

Home Management:

• Humidified air: Maintain at least 50% relative humidity in the child's room 3
• Adequate hydration: Ensure oral fluid intake 4
• Fever control: Use antipyretics as needed 4

What NOT to Use:

• Avoid over-the-counter cough medications: Little benefit and potential risks 1
• No antibiotics: Croup is viral and antibiotics are not indicated 1
• No antihistamines or decongestants: No proven effect on viral croup 4

Common Pitfalls to Avoid

1. Underdosing dexamethasone: Lower doses than 0.15 mg/kg have proven ineffective. 3
2. Discharging too soon after epinephrine: Must observe for at least 2 hours due to rebound risk. 1, 3
3. Using epinephrine for outpatient management: The short duration of action makes this unsafe without prolonged observation. 2
4. Prescribing antibiotics: Croup is viral and does not require antibacterial therapy. 1