What is the appropriate treatment for a preschool‑aged child with mild croup presenting with a barking cough and stridor only when upset and minimal or no chest wall retractions?

Treatment of Mild Croup

For a preschool-aged child with mild croup (barking cough and stridor only when upset, minimal or no retractions), administer a single dose of oral dexamethasone 0.15–0.6 mg/kg (maximum 10–12 mg) and discharge home with clear return precautions. 1

Initial Assessment

Mild croup is characterized by:

• Barking "seal-like" cough 2
• Stridor only when agitated or crying (not at rest) 1
• Minimal or absent chest wall retractions 1
• Normal oxygen saturation 1
• Ability to drink fluids normally 1

No radiographic studies are needed unless you suspect an alternative diagnosis such as foreign body aspiration or bacterial tracheitis. 1, 2

Pharmacologic Management

Corticosteroids (First-Line and Sufficient)

• Administer oral dexamethasone 0.15–0.6 mg/kg as a single dose (maximum 10–12 mg). 1, 3, 4
• Lower doses (0.15 mg/kg) are effective for mild disease, while higher doses (0.6 mg/kg) are traditionally used but may not be necessary. 3, 4, 5
• Oral dexamethasone is preferred over intramuscular administration for mild cases due to ease of delivery and equivalent efficacy. 5
• Nebulized budesonide 2 mg is an alternative if oral administration is not feasible, though oral dexamethasone remains first-line. 1, 4

What NOT to Use

• Do NOT administer nebulized epinephrine in mild croup. Epinephrine is reserved for moderate-to-severe cases with stridor at rest or significant respiratory distress, and should never be used in outpatient settings due to rebound risk. 1, 2, 3
• Do NOT prescribe over-the-counter cough or cold medications—they provide no benefit and may cause harm. 1, 2, 3
• Do NOT give antibiotics—croup is viral and antibiotics are ineffective. 3
• Do NOT give antihistamines or decongestants—they are ineffective for croup. 2, 6
• Avoid aspirin in children under 16 years due to Reye's syndrome risk. 1

Supportive Care at Home

• Encourage regular fluid intake to prevent dehydration, but do not force fluids if the child is vomiting. 1
• Use antipyretics (acetaminophen or ibuprofen) for fever control and comfort. 2, 6
• Humidified air has no proven benefit but is not harmful if parents wish to use it. 2, 7
• Cold air exposure similarly lacks evidence of benefit. 2

Discharge Criteria and Return Precautions

The child can be safely discharged home if:

• Stridor is absent at rest 2
• Minimal or no respiratory distress 1
• Adequate oral intake 1
• Reliable caregiver able to monitor and return if needed 2

Critical Warning Signs Requiring Immediate Return

Instruct parents to return immediately or call emergency services if:

• Stridor at rest develops (indicates progression to moderate-severe disease) 1, 3
• Respiratory rate >50 breaths/min (or >70 in infants) 1, 2
• Visible chest wall retractions or use of accessory muscles 2
• Cyanosis (blue lips or skin) or oxygen saturation <92% 1
• Inability to drink fluids or signs of dehydration 1, 3
• Extreme fatigue, lethargy, or difficulty staying awake—this signals hypoxia, not simple tiredness 1
• Agitation or restlessness—may reflect hypoxemia rather than anxiety 1, 2

Follow-Up

• Contact the child's physician if symptoms do not improve within 48 hours or worsen at any time. 1, 2
• If the child has recurrent episodes of croup, consider evaluation for asthma or underlying airway abnormalities (laryngomalacia, tracheomalacia). 2

Common Pitfalls to Avoid

• Do not use nebulized epinephrine in mild croup—it is unnecessary and creates risk of rebound symptoms if the child is discharged. 1, 3
• Do not withhold corticosteroids in mild cases—even mild croup benefits from a single dose of dexamethasone to reduce symptom duration and prevent progression. 1, 4, 5
• Do not discharge without clear return precautions—parents must understand the warning signs that require immediate medical attention. 1
• Do not prescribe codeine-containing medications—they carry risk of respiratory depression. 1