Assessment and Management of Croup in Children
Initial Assessment
Croup is a clinical diagnosis characterized by the sudden onset of a barking "seal-like" cough, inspiratory stridor, and hoarseness, typically in children aged 6 months to 5 years. 1
Key Clinical Features to Assess Immediately
- Severity indicators: Ability to speak/cry normally, respiratory rate, heart rate, presence of stridor at rest, use of accessory muscles (tracheal tug, chest wall recession), and oxygen saturation 1
- Life-threatening signs: Silent chest, cyanosis, fatigue/exhaustion, poor respiratory effort, or agitation (which may signal hypoxemia rather than anxiety) 1
- Typical presentation: Sudden onset without antecedent cough, congestion, or fever distinguishes croup from other respiratory illnesses 1
Critical Differential Diagnoses to Exclude
- Bacterial tracheitis: Consider if child appears toxic or fails to respond to standard croup treatment 1
- Foreign body aspiration: Suspect with sudden onset, unilateral findings, or atypical presentation 1
- Epiglottitis: Rare but life-threatening; presents with drooling, tripod positioning, and toxic appearance 1
- Never perform blind finger sweeps in suspected foreign body cases, as this may push objects deeper into the airway 1
Diagnostic Studies
Radiographic studies are unnecessary and should be avoided unless there is concern for an alternative diagnosis. 1 Clinical assessment is superior to lateral neck radiographs for diagnosis. 1
Treatment Algorithm
All Severity Levels: Corticosteroids
Administer oral corticosteroids immediately to all children with croup, regardless of severity. 1
- Dexamethasone 0.15-0.60 mg/kg orally as a single dose (maximum 10 mg) is the preferred option 1
- Prednisolone 1-2 mg/kg (maximum 40 mg) if dexamethasone is unavailable 1
- Corticosteroids reduce symptom severity, return visits, emergency department visits, and hospitalizations 2, 3
Moderate to Severe Croup: Add Nebulized Epinephrine
For children with stridor at rest or respiratory distress, add nebulized epinephrine to corticosteroids. 1
- Dosage: 0.5 ml/kg of 1:1000 solution nebulized (racemic or L-epinephrine are equally effective) 1, 4
- Critical timing consideration: The effect lasts only 1-2 hours 1
- Mandatory observation: Monitor for at least 2 hours after the last epinephrine dose to assess for rebound symptoms 1
- Never use nebulized epinephrine in outpatient settings where immediate return is not feasible, as rebound symptoms can occur 1
Oxygen Therapy
- Administer supplemental oxygen to maintain SpO₂ ≥94% using nasal cannulae, head box, or face mask 1
- Recognize that agitation may indicate hypoxemia requiring oxygen rather than anxiety 1
- Monitor oxygen saturation at least every 4 hours while on oxygen therapy 1
Supportive Care
- Minimize handling of severely ill children to reduce metabolic demand and oxygen consumption 1
- Antipyretics can be used for comfort 1
- Avoid chest physiotherapy as it provides no benefit and may cause harm 1
- Do not use over-the-counter cough or cold medications, antihistamines, or decongestants as they provide no therapeutic benefit and may cause harm 1, 5
- Humidified or cold air has no proven benefit for croup symptoms 1, 6
Hospitalization Criteria
Admit to hospital when any of the following are present: 1
- Three or more doses of racemic epinephrine required (this criterion alone reduces hospitalization rates by 37% without increasing revisits or readmissions) 1
- Age <18 months with severe symptoms 1
- Oxygen saturation <92% on room air 1
- Respiratory rate >70 breaths/min 1
- Persistent respiratory distress 1
- Family unable to provide appropriate observation or supervision at home 1
Discharge Criteria
Children may be discharged when ALL of the following are met: 1
- At least 2 hours have elapsed since the last nebulized epinephrine dose with no rebound symptoms 1
- Oxygen saturation >92% on room air 1
- No signs of respiratory distress 1
- Respiratory rate <50 breaths/min 1
- A reliable caregiver able to monitor the child and seek care if needed 1
Discharge Instructions
- Return immediately to the emergency department if respiratory distress worsens, stridor increases, or the child cannot maintain adequate hydration 1
- Follow up with primary care provider if symptoms have not improved within 48 hours 1
- Emphasize maintaining adequate fluid intake to prevent dehydration 1
- Provide antipyretics for fever control 1
Special Considerations
Recurrent Croup Episodes
Consider asthma as a differential diagnosis when croup recurs, especially if: 1
- Cough worsens at night 1
- Episodes are triggered by exercise or irritants 1
- Family history of asthma or atopy is present 1
- Child has atopic dermatitis 1
Prophylactic inhaled corticosteroids may benefit children with recurrent croup and features of atopy or gastroesophageal reflux. 1
Severe or Atypical Presentations
Flexible bronchoscopy should be performed in cases of: 1
- Severe or persistent symptoms not responding to standard treatment 1
- Associated hoarseness 1
- Oxygen desaturation or apnea 1
- Atypical presentation raising concern for anatomic abnormality (up to 68% of such infants have concomitant lower airway abnormalities) 1
Positioning for Airway Patency
For children under 2 years, use a neutral head position with a roll under the shoulders to optimize airway patency. 1
Common Pitfalls to Avoid
- Never discharge within 2 hours of nebulized epinephrine due to risk of rebound symptoms 1
- Never rely on radiographs for diagnosis when clinical presentation is consistent with croup 1
- Never use nebulized epinephrine in children who will be discharged immediately or managed on an outpatient basis 1
- Never perform blind finger sweeps in suspected foreign body aspiration 1
- Do not prescribe OTC cough medications, antihistamines, or decongestants as they are ineffective and potentially harmful 1, 5
- Do not use humidified air therapy as evidence shows no benefit 1, 6