How should I manage an 18‑month‑old child with croup (laryngotracheobronchitis)?

Management of Croup in an 18-Month-Old

Administer oral dexamethasone 0.15-0.6 mg/kg (maximum 10-12 mg) as a single dose immediately, regardless of severity, and add nebulized epinephrine (0.5 ml/kg of 1:1000 solution, maximum 5 ml) only if the child has stridor at rest or signs of respiratory distress. 1, 2

Initial Assessment

Evaluate the child for key severity indicators:

• Stridor at rest (versus only with agitation) 1
• Use of accessory muscles, tracheal tug, or chest wall retractions 1
• Respiratory rate (tachypnea >70 breaths/min suggests severe disease) 1
• Oxygen saturation (maintain ≥94%) 1, 2
• Agitation (may indicate hypoxemia, not anxiety) 1, 2
• Ability to speak/cry normally 1

Life-threatening signs requiring immediate intervention include silent chest, cyanosis, fatigue/exhaustion, or poor respiratory effort. 1

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

Treatment Algorithm

All Cases (Mild, Moderate, and Severe)

Give oral dexamethasone 0.15-0.6 mg/kg (maximum 10-12 mg) as a single dose. 1, 2, 4, 5, 3 This is the mainstay of treatment and reduces hospitalizations, length of illness, and need for subsequent treatments. 4, 3

• If the child cannot tolerate oral medication due to vomiting or severe distress, use intramuscular dexamethasone at the same dose 4
• Alternatively, nebulized budesonide 2 mg is equally effective when oral administration is not feasible 2, 6, 5

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

Add nebulized epinephrine 0.5 ml/kg of 1:1000 solution (maximum 5 ml). 1, 2, 6, 5, 3

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

Supportive Care

• Administer supplemental oxygen via nasal cannula, head box, or face mask to maintain SpO₂ ≥94% 1, 2
• Position the child with a neutral head position (roll under shoulders for children under 2 years) to optimize airway patency 1
• Minimize handling to reduce metabolic demand and oxygen consumption 1, 2
• Use antipyretics for fever control and comfort 1, 2
• Monitor oxygen saturation at least every 4 hours while on supplemental oxygen 1, 2

Hospitalization Criteria

Admit the child if ANY of the following are present:

• Need for ≥3 doses of nebulized epinephrine 1, 2, 6 (implementing "3 is the new 2" reduces admissions by 37% without increasing revisits) 1, 2
• Oxygen saturation <92% on room air 1, 2
• Age <18 months with severe symptoms 1, 2
• Respiratory rate >70 breaths/min 1, 2
• Persistent difficulty breathing despite treatment 2, 6
• Family unable to provide appropriate observation at home 1, 2

Discharge Criteria

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

• At least 2 hours have elapsed since the last nebulized epinephrine dose with no rebound symptoms 1, 2, 6
• Oxygen saturation >92% on room air 1, 2
• No stridor at rest and minimal/no respiratory distress 1, 2
• Respiratory rate <50 breaths/min 1
• Adequate oral intake 2
• Reliable caregiver able to monitor and return if worsening 1, 2

Discharge Instructions

• Return immediately if respiratory distress worsens, stridor increases, or the child cannot maintain hydration 1
• Follow up with primary care if not improving within 48 hours 1, 2
• Continue antipyretics for fever control 1, 2
• Do NOT give over-the-counter cough or cold medications (no benefit and potential harm) 1, 2
• Do NOT give antihistamines, decongestants, or antibiotics (ineffective for viral croup) 1

Critical Pitfalls to Avoid

• Never discharge within 2 hours of nebulized epinephrine administration due to risk of rebound symptoms 1, 2, 6
• Never use nebulized epinephrine in outpatient settings where immediate return is not feasible 1, 2, 6
• Do not admit after only 1-2 doses of epinephrine when a third dose could be given safely in the ED with appropriate observation 2
• Do not perform blind finger sweeps if foreign body aspiration is suspected (may push object deeper) 1
• Do not use chest physiotherapy (no benefit and may cause harm) 1, 2
• Avoid codeine-containing medications due to risk of respiratory depression 2

Special Considerations for This 18-Month-Old

This child's age (18 months) places them in a higher-risk category for admission if symptoms are severe. 1, 2 At this age, the airway is smaller and more prone to significant obstruction. If the child requires multiple doses of epinephrine or has persistent respiratory distress, strongly consider admission rather than extended observation. 1, 2

If this child has recurrent episodes of croup, consider evaluation for underlying airway abnormalities (laryngomalacia, tracheomalacia) or asthma after the acute episode resolves, as up to 68% of infants with severe/persistent stridor have concomitant lower airway abnormalities. 1