From the Guidelines
Croup management should prioritize outpatient treatment with a single dose of oral dexamethasone (0.15-0.6 mg/kg, maximum 10 mg) for mild to moderate symptoms, and hospital admission should be limited to severe cases requiring multiple doses of racemic epinephrine (RE). This approach is supported by a recent study published in Pediatrics in 2022 1, which demonstrated a 37% reduced rate of hospital admission without significant increase in revisits or readmissions when a clinical guideline and orderset were implemented. The study found that limiting hospital admission until 3 doses of RE are needed can lead to improved outcomes and reduced resource use.
Key considerations in managing croup include:
- Most cases can be managed at home with humidified air from a steamy bathroom or cool mist humidifier
- Oral dexamethasone is recommended for mild to moderate symptoms to reduce airway inflammation and improve symptoms within 2-3 hours
- Severe cases with respiratory distress require immediate medical attention and may need nebulized epinephrine in a hospital setting
- Symptoms typically worsen at night and improve during the day, with the illness usually resolving within 3-7 days
It is essential to keep the child calm and upright, as crying and agitation can worsen symptoms by increasing airway demands. By prioritizing outpatient treatment and limiting hospital admission to severe cases, healthcare providers can improve outcomes and reduce unnecessary resource use for patients with croup, as demonstrated by the study published in Pediatrics in 2022 1.
From the Research
Definition and Symptoms of Croup
- Croup is a common illness characterized by the abrupt onset of a barking cough, inspiratory stridor, hoarseness, and respiratory distress due to upper airway obstruction 2.
- Symptoms usually start like an upper respiratory tract infection, with low-grade fever and coryza followed by a barking cough and various degrees of respiratory distress 3.
- Croup affects about 3% of children per year, usually between the ages of 6 months and 3 years, and 75% of infections are caused by parainfluenza virus 2, 4.
Diagnosis and Differential Diagnosis
- Croup must be differentiated from acute epiglottitis, bacterial tracheitis, or an inhaled foreign body 2, 4.
- The assessment of airway, breathing, and circulation, focusing on airway, is paramount in treating croup 5.
- Physicians should consider other diagnoses, including bacterial tracheitis, epiglottitis, foreign body aspiration, peritonsillar abscess, retropharyngeal abscess, and angioedema 3.
Treatment Options
- A single dose of dexamethasone (0.15 to 0.60 mg per kg usually given orally) is recommended in all patients with croup, including those with mild disease 3, 6.
- Nebulized epinephrine is an accepted treatment in patients with moderate to severe croup 3, 6.
- Corticosteroids, such as prednisolone, may decrease the intensity of viral croup symptoms irrespective of their severity on presentation to the emergency department 6.
- Heliox can potentially reduce the work of breathing related to upper airway obstruction, but humidification therapy has not been proven beneficial 3, 6.