How should croup in children aged 6 months to 3 years be assessed for severity and managed?

Croup Assessment and Management in Children Aged 6 Months to 3 Years

Immediate Clinical Assessment

Assess severity immediately by evaluating stridor at rest, respiratory rate, use of accessory muscles (retractions, tracheal tug, chest wall recession), oxygen saturation, and ability to speak/cry normally. 1

Key severity indicators to document:

• Stridor at rest indicates moderate-to-severe disease requiring nebulized epinephrine 1
• Oxygen saturation <92% mandates hospital admission 2
• Life-threatening signs (silent chest, cyanosis, fatigue/exhaustion, poor respiratory effort) require immediate ICU-level care 1
• Agitation may signal hypoxemia rather than anxiety and warrants oxygen therapy 1

Critical Differential Diagnoses to Exclude

Before confirming croup, actively rule out:

• Bacterial tracheitis (toxic appearance, high fever, rapid deterioration) 1, 3
• Foreign body aspiration (sudden onset without prodrome, unilateral findings) 1, 3
• Epiglottitis (drooling, tripod positioning, toxic appearance) 3
• Retropharyngeal or peritonsillar abscess (neck stiffness, dysphagia, asymmetric findings) 1

Radiographic studies are unnecessary for typical croup and should be avoided unless alternative diagnoses are suspected. 1

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Treatment Algorithm

All Severity Levels: Universal Corticosteroid Administration

Administer oral dexamethasone 0.15-0.60 mg/kg (maximum 10 mg) as a single dose to ALL children with croup, regardless of severity. 1 This is the cornerstone of treatment and reduces symptom severity, return visits, and hospitalization rates. 4, 5

Alternative if dexamethasone unavailable: prednisolone 1-2 mg/kg (maximum 40 mg) 1

Moderate-to-Severe Croup: Add Nebulized Epinephrine

For children with stridor at rest or respiratory distress, immediately add nebulized epinephrine 0.5 mL/kg of 1:1000 solution (racemic epinephrine 0.5 mL of 2.25% solution diluted in 2.5 mL saline). 1, 6, 7

Critical timing considerations:

• Epinephrine effect lasts only 1-2 hours 1
• Mandatory 2-hour observation period after each epinephrine dose to monitor for rebound symptoms 1
• Never discharge within 2 hours of nebulized epinephrine administration 1
• Restart the 2-hour observation clock after each subsequent dose 1

Supportive Care

Administer supplemental oxygen to maintain SpO₂ ≥94% using nasal cannulae, head box, or face mask. 1 Oxygen should be applied even when stridor is present, as hypoxemia can develop rapidly. 1

Additional supportive measures:

• Minimize handling to reduce metabolic demand and oxygen consumption 1
• Antipyretics for fever control to improve comfort 1
• Maintain adequate hydration (oral preferred; if IV needed, use 80% basal maintenance rates) 1
• Avoid nasogastric tubes in severely ill children as they may compromise the airway 1
• Chest physiotherapy offers no benefit and should not be performed 1

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Hospitalization Criteria

Admit to hospital when:

• Three or more doses of racemic epinephrine are required 1
• Oxygen saturation <92% on room air 2
• Age <18 months with severe symptoms 1, 3
• Respiratory rate >70 breaths/min 1
• Family unable to provide appropriate observation or unreliable follow-up 1

Recent evidence demonstrates that limiting admission until 3 doses of racemic epinephrine are needed reduces hospitalization rates by 37% without increasing revisits or readmissions. 1

ICU-Level Care Indications

Transfer to ICU or continuous monitoring unit if:

• Impending respiratory failure (severe retractions, exhaustion, altered mental status) 2
• SpO₂ ≤92% on FiO₂ ≥0.50 2
• Sustained tachycardia, inadequate blood pressure, or need for vasopressor support 2
• Altered mental status from hypercarbia or hypoxemia 2
• Requires invasive or noninvasive positive pressure ventilation 2

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Discharge Criteria

Children 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 (or <40 in older children) 1
• Reliable caregiver able to monitor and return if needed 1

Discharge Instructions

Instruct families to:

• Return immediately to ED if respiratory distress worsens, stridor increases, or child cannot maintain hydration 1
• Follow up with primary care if symptoms not improved within 48 hours 1
• Use antipyretics for fever control 1
• Maintain adequate fluid intake 1

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Special Considerations and Pitfalls

Age-Specific Concerns

Infants 2-3 months with croup-like symptoms require heightened vigilance. 3 Croup is uncommon at this age (median presentation 23 months), making alternative diagnoses more likely. 3 These young infants warrant hospital admission and thorough evaluation for bacterial tracheitis, foreign body, or congenital airway abnormalities. 3

Recurrent Croup Episodes

Consider asthma as a differential diagnosis in children with recurrent croup, especially if episodes are triggered by exercise/irritants, worsen at night, or there is family history of asthma/atopy. 1 Gastroesophageal reflux (vomiting, feeding difficulties) should also be considered. 1

For severe, persistent, or atypical stridor, flexible bronchoscopy is recommended as approximately 68% of such infants have associated lower airway abnormalities. 1

Critical Medications to Avoid

Never use:

• Over-the-counter cough or cold medications (no therapeutic benefit, potential harm) 1, 8
• Antihistamines or decongestants (ineffective and carry adverse effects) 1, 8
• Honey (only helpful for post-viral cough, not acute croup; contraindicated <12 months due to botulism risk) 1, 8

Common Clinical Pitfalls

• Do not perform blind finger sweeps for suspected foreign body, as this may push objects deeper 1
• Do not rely on lateral neck radiographs for diagnosis; clinical assessment is superior 1
• Do not use nebulized epinephrine in outpatient settings where immediate return is not feasible due to rebound risk 1
• Humidified or heated air has no proven benefit for croup symptoms 1

Positioning for Airway Optimization

For children under 2 years, use a neutral head position with a roll under the shoulders to optimize airway patency. 1