How should I manage croup in a child aged 6 months to 3 years presenting with a barking cough and inspiratory stridor?

Management of Croup in Children Aged 6 Months to 3 Years

All children with croup should receive a single dose of oral dexamethasone (0.15-0.60 mg/kg, maximum 10 mg) immediately upon diagnosis, regardless of severity, with nebulized epinephrine (0.5 mL/kg of 1:1000 solution) added only for moderate-to-severe cases with stridor at rest or respiratory distress. 1

Immediate Assessment

When a child presents with barking cough and inspiratory stridor, rapidly assess for:

• Severity indicators: ability to speak/cry normally, respiratory rate, heart rate, presence of stridor at rest, use of accessory muscles (tracheal tug, chest wall recession), and oxygen saturation 1
• Life-threatening signs: silent chest, cyanosis, fatigue/exhaustion, poor respiratory effort, or agitation (which may signal hypoxemia rather than anxiety) 1
• Differential diagnoses to exclude: foreign body aspiration, bacterial tracheitis, epiglottitis, and retropharyngeal abscess 1

Critical pitfall: Do not perform blind finger sweeps if foreign body is suspected, as this may push objects deeper into the pharynx. 1

Treatment Algorithm

All Severity Levels (Mild, Moderate, Severe)

Administer oral dexamethasone 0.15-0.60 mg/kg (maximum 10 mg) as a single dose immediately. 1 If the child cannot tolerate oral medication, prednisolone 1-2 mg/kg (maximum 40 mg) is an alternative. 1

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

Add nebulized epinephrine 0.5 mL/kg of 1:1000 solution. 1, 2 The effect is rapid but short-lived, lasting only 1-2 hours. 1

Observe for at least 2 hours after each epinephrine dose to monitor for rebound symptoms. 1, 3 If a second dose is needed, restart the 2-hour observation clock. 1

Oxygen Therapy

Administer supplemental oxygen to maintain SpO₂ ≥94% using nasal cannulae, head box, or face mask—even when stridor is present. 1 Hypoxemia can develop rapidly in this age group. 1

Hospitalization Criteria

Admit the child if:

• Three or more doses of nebulized epinephrine are required 1
• Oxygen saturation <92% on room air 1
• Age <18 months with severe symptoms 1
• Respiratory rate >70 breaths/min (infants) or >50 breaths/min (older children) 1
• Family unable to provide appropriate observation at home 1

Evidence note: Recent guidelines demonstrate that limiting admission until 3 doses of epinephrine are needed reduces hospitalization rates by 37% without increasing revisits or readmissions. 1

Discharge Criteria

The child may be discharged when ALL of the following are met:

• At least 2 hours elapsed since last nebulized epinephrine with no rebound symptoms 1
• Oxygen saturation >92% on room air 1
• No signs of respiratory distress 1
• Respiratory rate <50 breaths/min 1
• Reliable caregiver able to monitor and return if needed 1

Home Management Instructions

Supportive care:

• Use antipyretics for fever control to improve comfort 1
• Maintain adequate hydration 1
• Minimize handling of severely ill children to reduce oxygen demand 1
• Position child in neutral head position (for children under 2 years, use a roll under shoulders) 1

What NOT to do:

• Do not give over-the-counter cough or cold medications—they provide no benefit and may cause harm 1
• Do not give antihistamines or decongestants—they are ineffective for croup 1
• Do not use chest physiotherapy—it offers no benefit and may cause harm 1
• Do not rely on humidified or cold air—current evidence shows no benefit 1

Follow-Up and Red Flags

Instruct families to return immediately if:

• Respiratory distress worsens 1
• Stridor increases 1
• Child cannot maintain adequate hydration 1
• Oxygen saturation drops (if home monitoring available) 1

Schedule follow-up with primary care provider if symptoms have not improved within 48 hours. 1

Special Considerations

For recurrent croup episodes, consider asthma as a differential diagnosis, especially if cough worsens at night, episodes are triggered by exercise or irritants, or there is family history of asthma or atopy. 1 Prophylactic inhaled corticosteroids may be beneficial in these cases. 1

If symptoms are severe, persistent, or atypical, flexible bronchoscopy should be performed, as approximately 68% of such infants have associated lower airway abnormalities. 1

Radiographic studies are generally unnecessary and should be avoided unless there is concern for an alternative diagnosis. 1 Clinical assessment is more important than imaging. 1