What is the recommended treatment for viral laryngotracheobronchitis (croup) in children aged 6 months to 3 years, including corticosteroid dosing and indications for nebulized epinephrine?

Treatment for Croup in Children

For children aged 6 months to 3 years with viral laryngotracheobronchitis (croup), administer a single dose of oral dexamethasone 0.6 mg/kg (maximum 10-12 mg) as first-line therapy, and reserve nebulized epinephrine (0.5 mL/kg of 1:1000 solution up to 5 mL) for moderate to severe cases with significant respiratory distress. 1, 2, 3

Corticosteroid Therapy: The Foundation of Treatment

Dexamethasone is the mainstay of croup treatment and should be given to all children presenting with croup, regardless of severity. 3, 4

• Dosing: Administer dexamethasone 0.6 mg/kg orally (maximum 10-12 mg) as a single dose 2, 3, 5
• Route selection: Use oral route when possible; reserve intramuscular administration for children who are vomiting or in severe respiratory distress unable to tolerate oral medication 3, 5
• Onset of action: Expect clinical improvement approximately 6 hours after administration, though some reduction in croup scores may be seen as early as 1 hour 2, 6
• Lower dose consideration: While 0.15 mg/kg has been shown equally effective as 0.6 mg/kg in some studies, the standard 0.6 mg/kg dose remains recommended because lower doses have historically proven ineffective 2, 6

Alternative corticosteroid option: Nebulized budesonide is effective and equally beneficial as oral dexamethasone, though oral dexamethasone is preferred due to ease of administration, availability, and lower cost 1, 3

Nebulized Epinephrine: For Moderate to Severe Cases

Reserve nebulized epinephrine for children with moderate to severe croup showing significant respiratory distress, inspiratory stridor at rest, or retractions. 1, 4

• Dosing options: Either 0.5 mL/kg of 1:1000 L-epinephrine solution (maximum 5 mL) OR 0.5 mL of 2.25% racemic epinephrine diluted in 2-2.5 mL normal saline, administered by nebulizer 1, 5
• Rapid but transient effect: Epinephrine provides quick reversal of airway obstruction within 30 minutes, but effects last only approximately 2 hours 1, 2
• Mandatory observation period: Monitor all children for at least 2 hours after epinephrine administration to watch for rebound airway obstruction 2, 5
• Simultaneous corticosteroid administration: Always give dexamethasone concurrently with epinephrine to provide sustained benefit once the epinephrine effect wears off 2, 4

Hospitalization Criteria

Admit children who require two or more epinephrine treatments, as this indicates more severe disease. 5

Additional indications for hospitalization include: 4

• Persistent respiratory distress after initial treatment
• Inability to maintain adequate hydration
• Hypoxemia requiring supplemental oxygen
• Concerns about caregiver ability to monitor at home

Supportive Care Measures

• Humidification: Maintain at least 50% relative humidity in the child's environment; consider mist tent with supplemental oxygen if hypoxemia is present 2
• Hydration: Ensure adequate fluid intake 5
• Fever control: Manage fever as needed 5

Critical Pitfalls to Avoid

Do not use antibiotics, antihistamines, or decongestants for uncomplicated viral croup, as they have no proven benefit. 5

• Avoid nebulized corticosteroids in routine croup management: While nebulized budesonide is effective for croup, hand-held inhalers with spacers have NOT been shown effective for this condition, unlike in asthma 1
• Do not withhold corticosteroids in mild croup: Evidence supports treating all children with croup who seek medical care, as early intervention reduces symptom severity and prevents return visits 3, 4
• Do not confuse croup with bronchiolitis: Nebulized corticosteroids and beta-agonists are ineffective in bronchiolitis, which is a distinct lower airway disease 1

Clinical Assessment Points

Look for these specific features to gauge severity: 2, 4

• Inspiratory stridor: Present at rest in moderate to severe cases
• Barking cough: Characteristic seal-like quality
• Retractions: Suprasternal, intercostal, or subcostal
• Hypoxemia: Oxygen saturation <92% indicates severe disease
• Preceding upper respiratory infection: Typically present 1-2 days before croup symptoms
• Low-grade fever: Usually present but high fever should prompt consideration of bacterial tracheitis or epiglottitis