Should I admit a child with croup?

Admission Criteria for Pediatric Croup

You should admit a child with croup only after they require 3 or more doses of nebulized epinephrine, not the traditional 2 doses, as this approach reduces hospitalizations by 37% without increasing revisits or adverse outcomes. 1, 2

Modern Evidence-Based Hospitalization Criteria

The American Academy of Pediatrics now supports the "3 is the new 2" approach, which represents a significant shift from traditional practice. 2 This updated guideline is based on high-quality 2022 data showing that:

• Admission rate after ≤2 doses of epinephrine dropped from 6.3% to 1.7% when implementing extended observation protocols 1
• No increase in 72-hour revisits or ICU transfers occurred with this more conservative approach 1
• Patients receiving >2 doses still had similar admission rates (81.8% vs 83.3%), confirming that 3 doses is the appropriate threshold 1

Specific Admission Indications

Admit the child when any of the following are present:

• ≥3 doses of nebulized epinephrine required 2, 3, 4
• Oxygen saturation <92% on room air 2, 4
• Age <18 months with severe symptoms 2, 4
• Respiratory rate >70 breaths/min 2, 4
• Persistent stridor at rest despite treatment 3
• Signs of exhaustion, fatigue, or lethargy 2
• Silent chest or cyanosis (life-threatening signs) 4
• Family unable to provide appropriate observation at home 4

Critical Observation Protocol After Epinephrine

You must observe the patient for at least 2 hours after each dose of nebulized epinephrine before making any disposition decision. 2, 3, 4 This is non-negotiable because:

• Epinephrine effects last only 1-2 hours with significant rebound risk 2, 3, 4
• The observation clock restarts after each subsequent dose 4
• Discharging before 2 hours is a critical pitfall that can lead to untreated rebound symptoms 2, 3

Safe Discharge Criteria

You can safely discharge the child home when all of the following are met:

• ≥2 hours since last epinephrine dose without rebound symptoms 4
• No stridor at rest 2, 4
• Minimal or no respiratory distress 2, 4
• Oxygen saturation >92% on room air 4
• Respiratory rate <50 breaths/min (or <40 in older children) 4
• Adequate oral intake 2
• Reliable caregiver able to monitor and return if worsening 2, 4

Common Pitfalls to Avoid

• Admitting after only 1-2 doses of epinephrine when the child could safely receive a third dose in the ED with appropriate observation 2
• Discharging within 2 hours of epinephrine administration before assessing for rebound 2, 3
• Using epinephrine in outpatient settings where immediate return is not feasible 2, 3
• Failing to provide clear return precautions to parents about worsening stridor, respiratory distress, or inability to maintain hydration 4

Treatment While Deciding on Admission

While observing the patient:

• Administer oral dexamethasone 0.15-0.6 mg/kg (max 10-12 mg) to all patients regardless of severity 2
• Provide supplemental oxygen to maintain SpO₂ ≥94% 4
• Minimize handling to reduce metabolic demands in severely ill children 4
• Monitor oxygen saturation at least every 4 hours 4
• Recognize that agitation may signal hypoxemia, not anxiety 4

The key paradigm shift is that most children who previously would have been admitted after 2 doses of epinephrine can now be safely managed with a third dose and extended observation in the ED, reserving admission for those who truly need inpatient monitoring. 1, 2