How should I assess severity and manage croup in a 6‑month‑to‑3‑year‑old child presenting with a barking cough, stridor (at rest or with agitation), retractions, and variable oxygen saturation?

Management of Croup in Children

Administer a single dose of oral dexamethasone 0.6 mg/kg to all children with croup regardless of severity, and add nebulized racemic epinephrine for those with moderate-to-severe disease (stridor at rest, retractions, or respiratory distress). 1, 2

Severity Assessment

Classify croup severity using the following clinical features to guide treatment decisions:

Mild croup:

• Barking cough with stridor only during agitation or crying
• No retractions at rest
• Normal oxygen saturation
• Child appears comfortable when calm 2

Moderate-to-severe croup:

• Stridor at rest (audible without stethoscope)
• Visible chest wall retractions (suprasternal, subcostal, or intercostal)
• Increased work of breathing
• Agitation or lethargy (may indicate hypoxemia)
• Oxygen saturation <92% 3, 1, 2

Pharmacologic Management

Corticosteroids (First-Line for All Severities)

Oral dexamethasone is the definitive treatment for croup at any severity level. 4, 1

• Dose: 0.6 mg/kg as a single oral dose (maximum 10 mg) 3, 4, 1
• Onset of action: Approximately 6 hours 3
• Efficacy: Reduces symptom severity, return visits, emergency department visits, hospital admissions, and length of stay 4, 5, 1
• Lower doses (0.15 mg/kg) may be effective but 0.6 mg/kg is the established standard 4, 2

Alternative corticosteroid options if oral route not tolerated:

• Intramuscular dexamethasone 0.6 mg/kg (equally effective as oral) 4, 5
• Nebulized budesonide 2 mg (reasonable alternative but less convenient) 4, 5, 2

Nebulized Epinephrine (Add for Moderate-to-Severe Croup)

Reserve nebulized epinephrine for children with stridor at rest, retractions, or significant respiratory distress. 5, 1, 2

• Indication: Moderate-to-severe croup only 5, 1
• Mechanism: Rapidly reverses airway obstruction within minutes 3
• Dose: Racemic epinephrine 0.05 mL/kg (maximum 0.5 mL) diluted in 3 mL normal saline via nebulizer 3
• Critical caveat: Observe for at least 2 hours after administration due to risk of rebound airway obstruction 3, 1
• Combined therapy: Simultaneous administration with corticosteroids reduces intubation rates in severe croup with impending respiratory failure 5

Supportive Care

Maintain at least 50% relative humidity in the child's environment, though evidence for mist therapy is limited. 3, 1

• Supplemental oxygen via nasal cannula or face mask if oxygen saturation ≤92% 6
• Avoid agitation—recognize that agitation may indicate hypoxemia rather than anxiety 6
• Antipyretics (acetaminophen or ibuprofen) for fever and comfort 6

Disposition and Monitoring

Criteria for Hospital Admission

Admit children with any of the following:

• Oxygen saturation <92% despite treatment 6
• Persistent stridor at rest after dexamethasone and epinephrine 1
• Significant retractions or increased work of breathing 6
• Inability to maintain oral hydration 6
• Concerns about family's ability to monitor at home 6

Outpatient Management (Mild Croup)

Children with mild croup who receive dexamethasone can be discharged home with close follow-up. 4, 5

• Observation period: Monitor for 2–4 hours after treatment to ensure improvement 3
• Parent education: Return immediately for worsening stridor, increased work of breathing, inability to drink, lethargy, or cyanosis 6
• Follow-up: Re-evaluate within 48 hours if not improving or if symptoms worsen 6

Common Pitfalls to Avoid

Do not withhold corticosteroids from children with mild croup—early intervention reduces symptom severity and prevents progression. 5, 2

Do not rely on mist therapy alone—while commonly used, published evidence does not support cool mist or cold air exposure as effective treatments. 2

Do not discharge children immediately after epinephrine—a minimum 2-hour observation period is mandatory due to rebound obstruction risk. 3, 1

Do not order routine laboratory studies or radiography—croup is a clinical diagnosis and imaging should be reserved only when alternative diagnoses (epiglottitis, bacterial tracheitis, foreign body) are suspected. 1

Do not use lower steroid doses than 0.6 mg/kg for initial treatment—lower dosages have proven ineffective in treating croup. 3