What is the appropriate management for a 17‑month‑old child presenting with croup?

Management of Croup in a 17-Month-Old Child

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

Initial Assessment

Evaluate the child for key severity indicators:

• Stridor at rest (indicates moderate to severe disease requiring epinephrine) 3
• Use of accessory muscles, chest wall retractions, nasal flaring (signs of respiratory distress) 3
• Respiratory rate (>70 breaths/min is a hospitalization criterion) 1, 2
• Oxygen saturation (<92% requires admission) 1, 2
• Agitation (may indicate hypoxemia rather than anxiety) 3
• Life-threatening signs such as silent chest, cyanosis, or extreme fatigue (require immediate escalation) 3

The diagnosis is clinical—do not obtain radiographs unless you suspect an alternative diagnosis such as foreign body aspiration, bacterial tracheitis, or retropharyngeal abscess. 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 This is the gold standard first-line treatment for all severities of croup. 1 If oral administration is not feasible due to vomiting or severe distress, nebulized budesonide 2 mg is equally effective. 2

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

Add nebulized epinephrine 0.5 mL/kg of 1:1000 solution (maximum 5 mL). 1, 2, 3 The effect is rapid but short-lived, lasting only 1-2 hours. 3

Critical observation requirement: You must observe the child for at least 2 hours after the last dose of epinephrine to monitor for rebound symptoms. 1, 2, 3 Never discharge a patient within this 2-hour window. 1, 3

If a second dose of epinephrine is needed, restart the 2-hour observation clock after each dose. 3

Supportive Care

• Administer supplemental oxygen via nasal cannula, head box, or face mask to maintain SpO₂ ≥94%. 2, 3
• Minimize handling of severely ill children to reduce metabolic demand and oxygen requirements. 3
• Use antipyretics for fever control to improve comfort. 2, 3
• Ensure adequate hydration but avoid nasogastric tubes in severely ill children as they can compromise the airway. 3
• Do not use chest physiotherapy—it offers no benefit and may cause harm. 3
• Do not give over-the-counter cough or cold medications, antihistamines, or decongestants—they provide no therapeutic benefit and may cause harm. 3
• Do not use antibiotics—croup is viral in etiology. 1, 2

Hospitalization Criteria

Admit the child if any of the following are present:

• ≥3 doses of nebulized epinephrine required (recent guidelines support "3 is the new 2," which reduces unnecessary admissions by 37% without increasing revisits) 1, 2, 3
• Oxygen saturation <92% 1, 2
• Age <18 months (this 17-month-old is in a high-risk age group) 1, 2, 3
• Respiratory rate >70 breaths/min 1, 2
• Persistent respiratory distress despite treatment 1, 2
• Family unable to provide appropriate observation at home 3

Discharge Criteria

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

• At least 2 hours have elapsed since the last nebulized epinephrine dose with no rebound symptoms 3
• Oxygen saturation >92% on room air 3
• No signs of respiratory distress 3
• Respiratory rate <50 breaths/min 3
• A reliable caregiver able to monitor the child and seek care if needed 2, 3

Discharge Instructions

Provide clear return precautions:

• Return immediately to the emergency department if respiratory distress worsens, stridor increases, or the child cannot maintain adequate hydration. 3
• Follow up with the primary care provider if symptoms have not improved within 48 hours. 2, 3
• Continue antipyretics for fever control and maintain adequate fluid intake. 3

Critical Pitfalls to Avoid

• Never discharge within 2 hours of epinephrine administration due to risk of rebound symptoms. 1, 3
• Never use epinephrine in outpatient settings where immediate return is not feasible. 1, 3
• Never admit after only 1-2 doses of epinephrine when a third dose could be safely given in the emergency department—this unnecessarily increases hospitalization rates. 1, 2
• Never rely on cool mist therapy as definitive treatment—it lacks evidence of benefit. 1, 3
• Never give codeine-containing medications due to risk of respiratory distress. 2

Special Considerations for This 17-Month-Old

At 17 months of age, this child falls into the high-risk category for hospitalization based on age alone (<18 months). 1, 2, 3 If the child requires even one dose of nebulized epinephrine, maintain a lower threshold for admission given the age and the potential for rapid deterioration in this age group.