Croup: Approach to management

Author:
Charles R Woods, MD, MS
Section Editors:
Sheldon L Kaplan, MD
Anna H Messner, MD
Deputy Editor:
Carrie Armsby, MD, MPH

Contributor Disclosures

All topics are updated as new evidence becomes available and our peer review
process is complete.
Literature review current through: Aug 2018. | This topic last updated: Sep 27,
2018.

INTRODUCTION — Croup (laryngotracheitis) is a respiratory illness characterized by

inspiratory stridor, barking cough, and hoarseness. It typically occurs in children six
months to three years of age and is chiefly caused by parainfluenza virus. (See "Croup:
Clinical features, evaluation, and diagnosis".)

Most children with croup who seek medical attention have a mild, self-limited illness
and can be successfully managed as outpatients. The clinician must be able to identify
children with mild symptoms, who can be safely managed at home, and those with
moderate to severe croup or rapidly progressing symptoms, who require full evaluation
and possible treatment in the office or emergency department setting. (See 'Severity
assessment' below and 'Outpatient treatment' below.)

There is no definitive treatment for the viruses that cause croup. Pharmacologic
therapy is directed toward decreasing airway edema, and supportive care is directed
toward the provision of respiratory support and the maintenance of hydration.
Corticosteroids and nebulized epinephrine are the cornerstones of therapy; their use is
supported by substantial clinical evidence. (See 'Initial treatment' below and "Croup:
Pharmacologic and supportive interventions".)

The approach to the management of croup will be discussed below. The clinical
features and evaluation of croup, and the evidence supporting the use of the
pharmacologic and supportive interventions included below are discussed separately.
(See "Croup: Clinical features, evaluation, and diagnosis" and "Croup: Pharmacologic
and supportive interventions".)

SEVERITY ASSESSMENT — This initial step in the management of a child with croup
is assessing severity of illness. The first contact with the health care system may occur
by phone, and the health care provider must be able to distinguish children with more
severe symptoms who need immediate medical attention from those who can be
managed at home. (See 'Telephone triage' below.)
When the child is seen in the office or emergency department, croup severity is
assessed by examining the child and using a clinical scoring system. (See 'Croup
severity score'below.)

Telephone triage — When assessing patients by phone, the health care provider must
distinguish children who need immediate medical attention or further evaluation from
those who can be managed at home. Children who need further evaluation include
those who have:

●Stridor at rest

●Rapid progression of symptoms (ie, symptoms of upper airway obstruction after

less than 12 hours of illness)

●Inability to tolerate oral fluids

●Underlying known airway abnormality (eg, subglottic stenosis, subglottic

hemangioma, previous intubation)

●Previous episodes of moderate to severe croup

●Medical conditions that predispose to respiratory failure (eg, neuromuscular

disorders or bronchopulmonary dysplasia)

●Parental concern that cannot be relieved by reassurance

●Prolonged symptoms (more than three to seven days) or an atypical course

(perhaps indicating an alternative diagnosis) (see "Croup: Clinical features,
evaluation, and diagnosis", section on 'Differential diagnosis')

Patients who are assessed by phone and determined to have mild symptoms and none
of the above indications for further evaluation can be managed at home. (See 'Home
treatment' below.)

Croup severity score — There are a number of validated croup scoring systems. The
Westley croup score has been the most extensively studied (table 1) (calculator 1) [1].
Severity is determined by the presence or absence of stridor at rest, the degree of
chest wall retractions, air entry, the presence or absence of pallor or cyanosis, and the
mental status. In a study that evaluated the individual components of the Westley croup
score, the degree of chest wall retractions and air entry were the strongest predictors of
need for hospitalization [2].

●Mild croup (Westley croup score of ≤2) − Children with mild croup have no
stridor at rest (although stridor may be present when upset or crying), a barking
cough, hoarse cry, and either no, or only mild, chest wall/subcostal retractions [3-
5]. (See 'Mild croup' below.)

●Moderate croup (Westley croup score of 3 to 7) − Children with moderate croup

have stridor at rest, have at least mild retractions, and may have other symptoms
 or signs of respiratory distress, but little or no agitation [3-5]. (See 'Moderate to
severe croup' below.)

●Severe croup (Westley croup score of ≥8) − Children with severe croup have
stridor at rest, although the loudness of the stridor may decrease with worsening
upper airway obstruction and decreased air entry [3-5]. Retractions are severe
(including indrawing of the sternum), and the child may appear anxious, agitated,
or pale and fatigued. Prompt recognition and treatment of children with severe
croup are paramount. (See 'Moderate to severe croup' below.)

●Impending respiratory failure (Westley croup score of ≥12) − Croup

occasionally results in severe upper airway obstruction with impending respiratory
failure, heralded by the following signs [3,5,6]:

•Fatigue and listlessness

•Marked retractions (although retractions may decrease with increased

obstruction and decreased air entry)

•Decreased or absent breath sounds

•Depressed level of consciousness

•Tachycardia out of proportion to fever

•Cyanosis or pallor

Patients who present to an office clinic with severe croup or signs and symptoms
of impending respiratory failure should be transported via emergency medical
services to an emergency department for management. (See 'Moderate to severe
croup' below.)

MILD CROUP — Children with mild symptoms (Westley croup score of ≤2 (table 1)
(calculator 1)) should be treated symptomatically with humidity, fever reduction, and
oral fluids. Many such children can be managed by phone, provided that none of the
criteria for further evaluation described above are present. (See 'Telephone
triage' above.)

Home treatment — The caregivers of children with mild croup who are managed at
home should be instructed in provision of supportive care including mist, antipyretics,
and encouragement of fluid intake.

In acute situations and for short periods of time, caregivers may try sitting with the child
in a bathroom filled with steam generated by running hot water from the shower to
improve symptoms. This may help reassure parents that "something" is being done to
reverse the symptoms, and anecdotal evidence supports some benefit with this
measure.

Exposure to cold night air also may lessen symptoms of mild croup, although this has
never been systematically studied. If parents or caregivers wish to use humidifiers at
home, only those that produce mist at room temperature should be used to avoid the
risk of burns from steam or the heating element.

Instructions should be provided to the caregivers regarding when to seek medical

attention, including watching for [3]:

●Stridor at rest

●Difficulty breathing

●Pallor or cyanosis

●Severe coughing spells

●Drooling or difficulty swallowing

●Fatigue

●Worsening course

●Fever (>38.5°C)

●Prolonged symptoms (longer than seven days)

●Suprasternal retractions

Caregivers also should be provided with some guidance regarding when it is safe for
them to drive the child to the emergency department; emergency medical services
should provide transportation for children who are severely agitated, pale or cyanotic,
struggling to breathe, or lethargic [3].

Patients who are managed at home should receive a follow-up phone call within 24
hours.

Outpatient treatment — We suggest that children with mild croup who are seen in the
outpatient setting be treated with a single dose of oral dexamethasone (0.15 to
0.6 mg/kg,maximum dose 16 mg) (algorithm 1). Randomized controlled trials in
children with mild croup have demonstrated that treatment with a single dose of oral
dexamethasone reduces the need for reevaluation, shortens the duration of symptoms,
improves the child's sleep, and reduces parental stress [7,8]. (See "Croup:
Pharmacologic and supportive interventions", section on 'Dexamethasone'.)

An alternative approach is nonpharmacologic management with anticipatory guidance

about potential worsening and instructions on when to seek care or return for follow-up.

Treatment with nebulized epinephrine is not typically necessary for management of

mild croup.

Children with mild croup who are tolerating fluids and have not received
nebulized epinephrine can be sent home after specific follow-up (which may occur by
phone) has been arranged and the caregiver has received instructions regarding home
care and indications to seek medical attention as described above. (See 'Home
treatment' above.)

MODERATE TO SEVERE CROUP

Setting and pace of treatment — The appropriate treatment setting depends upon
the severity of symptoms:

●Children with moderate croup (Westley croup score 3 to 7 – Stridor at rest and
mild to moderate retractions but no or little distress or agitation (table 1) (calculator
1)) should be evaluated in the emergency department or office (provided the office
is equipped to handle acute upper airway obstruction).

●Children with severe croup (Westley croup score ≥8 – Stridor at rest and marked
retractions with agitation, lethargy, or cyanosis (table 1) (calculator 1)) should be
evaluated in the emergency department as they require aggressive therapy,
monitoring, and supportive care.

The child with severe croup must be approached cautiously, as any increase in anxiety
may worsen airway obstruction. The parent or caregiver should be instructed to hold
and comfort the child. Nebulized epinephrine should be added as quickly as possible,
as described below. In the meantime, health care providers should continuously
observe the child and be prepared to provide bag-mask ventilation and advanced
airway techniques if the condition worsens (algorithm 1). (See 'Initial treatment' below
and 'Respiratory care' below.)

Initial treatment — Initial treatment of moderate to severe croup includes

administration of dexamethasone and nebulized epinephrine. Children with moderate
to severe croup should also receive supportive care including humidified air or oxygen,
antipyretics, and encouragement of fluid intake. (See 'Supportive care' below.)

We recommend administration of dexamethasone (0.6 mg/kg, maximum of 16 mg) in

all children with moderate to severe croup. Dexamethasone should be administered by
the least invasive route possible: oral if oral intake is tolerated, intravenous (IV) if IV
access has been established, or intramuscular (IM) if oral intake is not tolerated and IV
access has not been established. The oral preparation of dexamethasone
(1 mg/mL) has an unpleasant taste. The IV preparation is more concentrated (4 mg per
mL) and can be given orally mixed with syrup [3,9-11]. A single dose of
nebulized budesonide (2 mg [2 mL solution] via nebulizer) is an alternative option,
particularly for children who are vomiting and who lack IV access [3,5,12].

The benefit of corticosteroids for moderate to severe croup have been demonstrated in
a meta-analysis of 24 trials that found improvement in croup scores six hours after
treatment, fewer return visits or readmissions, decreased length of stay in the
emergency department or hospital, and decreased epinephrine use [8]. (See "Croup:
Pharmacologic and supportive interventions", section on 'Glucocorticoids'.)
In addition to dexamethasone, we recommend nebulized epinephrine in all patients
with moderate to severe croup:

●Racemic epinephrine is administered as 0.05 mL/kg per dose (maximum of 0.5

mL) of a 2.25 percent solution diluted to 3 mL total volume with normal saline. It is
given via nebulizer over 15 minutes.

●L-epinephrine (parenteral product) is administered as 0.5 mL/kg per dose

(maximum of 5 mL) using the 1 mg/mL strength (may also be referred to as a
1:1000 dilution). It is given via nebulizer over 15 minutes.

The benefits of nebulized epinephrine have been demonstrated in a meta-analysis of

eight trials that found improvement in croup score 30 minutes posttreatment and
shorter hospital stay; there was no difference in effectiveness between racemic
epinephrine and L-epinephrine [13]. (See "Croup: Pharmacologic and supportive
interventions", section on 'Nebulized epinephrine'.)

Observation and disposition — Patients should be observed for three to four hours
after initial treatment. The need for additional intervention and/or admission to the
hospital is determined chiefly by the response to therapy with corticosteroids and
nebulized epinephrine. The majority of children with moderate croup have symptomatic
improvement after treatment with nebulized epinephrine and corticosteroids and can be
discharged home, whereas those with severe symptoms on presentation are more
likely to require hospitalization.

Discharge to home — Patients who have a good response to initial treatment should
be observed for three to four hours after pharmacologic intervention (algorithm 1) [14-
17]. Croup symptoms usually improve within 30 minutes of administration of
nebulized epinephrine but may recur as the effects of epinephrine wear off (usually by
two hours) [18,19]. Children who have recurrence or worsening of moderate to severe
symptoms during the observation period should receive additional racemic epinephrine
and should be admitted to the hospital. (See 'Indications for hospital admission' below.)

After three to four hours of observation, children who remain comfortable may be
discharged home if they meet the following criteria [14-17]:

●No stridor at rest

●Normal pulse oximetry

●Good air exchange

●Normal color

●Normal level of consciousness

●Demonstrated ability to tolerate fluids by mouth

●Caregivers understand the indications for return to care and would be able to
return if necessary
Before discharge, follow-up with the primary care provider should be arranged within
the next 24 hours. Instructions regarding home treatment should be provided.
(See 'Home treatment' above.)

Approximately 5 percent of children well enough for discharge from the emergency
department after receiving corticosteroids and nebulized epinephrine treatments are
expected to return for care [20]. Relapse within 24 hours is unlikely in those who have
minimal symptoms at the time of discharge [21].

Indications for hospital admission — Patients with ongoing severe symptoms after
initial treatment should receive additional nebulized epinephrine and should be
admitted to the hospital. Nebulized epinephrine can be repeated every 15 to 20
minutes. The administration of three or more doses within a two- to three-hour time
period should prompt initiation of close cardiac monitoring if this is not already
underway.

Children with persistent moderate symptoms can be observed for at least four hours
before deciding whether they require hospital admission as the effect
of dexamethasone may not be apparent for several hours [3].

Indications for inpatient admission include [3,22]:

●Severe croup with poor air entry, altered consciousness, or impending

respiratory failure

●Moderate/severe croup with persistent or deteriorating respiratory distress after

treatment with nebulized epinephrine and corticosteroids

●"Toxic" appearance or clinical picture suggesting serious secondary bacterial

infection

●Need for supplemental oxygen

●Severe dehydration

Additional factors that influence the decision regarding admission include [3,22]:

●Young age, particularly younger than six months

●Recurrent visits to the emergency department within 24 hours

●Ability of the family to comprehend the instructions regarding recognition of

features that indicate the need to return for care

●Ability of the family to return for care (eg, distance from home to care
site, weather/travel conditions)

Admission to the pediatric intensive care unit (PICU) is warranted if any of the following
are present:
 ●Respiratory failure requiring endotracheal intubation

●Persistent severe symptoms requiring frequent nebulized epinephrine dosing

●Underlying conditions placing the child at high risk for progressive respiratory
failure (eg, neuromuscular disease or bronchopulmonary dysplasia)

Approximately 8 to 15 percent of children with croup presenting to the emergency

department require hospitalization; only 1 percent require admission to the PICU
[20,23,24]. Most children who are admitted have a brief inpatient stay [23].

Inpatient management — Children admitted to the hospital for management of croup

should receive close respiratory monitoring and supportive care.

Supportive care — Supportive care for children hospitalized with moderate to severe
croup includes:

●Fluids − Administration of intravenous fluids may be necessary in some children.

Fever and tachypnea may increase fluid requirements, and respiratory difficulty
may prevent the child from achieving adequate oral intake. (See "Maintenance
fluid therapy in children".)

●Fever control − High fever can contribute to tachypnea and respiratory distress
in children with croup, and treatment with antipyretics can improve work of
breathing and insensible fluid losses.

●Comfort − Care must be taken to avoid provoking agitation or anxiety in children

with moderate to severe croup as this can worsen the degree of respiratory
distress and airway obstruction. Children with severe croup should be approached
cautiously, and unnecessary invasive interventions should be avoided. The parent
or caregiver should be instructed to hold and comfort the child and to assist in
care. The use of sedatives or anxiolytics to reduce agitation is discouraged as this
may cause respiratory depression.

Respiratory care — Respiratory support for children hospitalized with croup may
include the following:

●Nebulized epinephrine − Repeated doses of nebulized epinephrine may be

warranted for children with moderate to severe distress. It is not always required;
one study of 365 hospitalizations for croup found that only 49 percent required
additional nebulized epinephrine during the inpatient stay [25]. Nebulized
epinephrine can be repeated every 15 to 20 minutes. However, children who
require frequent doses of epinephrine (eg, more frequently than every one to two
hours) should be admitted/transferred to an intensive care unit for close
cardiopulmonary monitoring. (See "Croup: Pharmacologic and supportive
interventions", section on 'Nebulized epinephrine'.)

●Supplemental oxygen − Oxygen should be administered to children who are

hypoxemic (oxygen saturation of <92 percent in room air). Supplemental oxygen
should be humidified to decrease drying effects on the airways, since drying may
impede the physiologic removal of airway secretions via mucociliary and cough
mechanisms. (See "Continuous oxygen delivery systems for infants, children, and
adults".)

●Mist − Humidified air is frequently used in the treatment of croup, although a

meta-analysis of three trials evaluating the use of humidified air in croup found
only marginal improvement in croup scores [26]. Mist therapy may provide a
sense of comfort and reassurance to both the child and family; however, if the
child is instead agitated by the mist, it should be discontinued. (See "Croup:
Pharmacologic and supportive interventions", section on 'Mist therapy'.)

●Heliox − Heliox is a mixture of helium (70 to 80 percent) and oxygen (20 to 30

percent). Heliox may decrease the work of breathing in children with croup by
reducing turbulent airflow. A meta-analysis of three trials concluded that while
there is evidence to suggest a short-term benefit of heliox, a larger trial is needed
before recommendations regarding the use of heliox in children with croup can be
made [27]. While the evidence from these trials does not suggest a large benefit
from Heliox to support its routine use in the management of croup, in patients with
severe symptoms who are at risk for respiratory failure, it may be used in an
attempt to avoid the need for intubation. An important limitation of heliox use is the
low fractional concentration of inspired oxygen (FiO2) in the gas mixture, which
may not be adequate for children with hypoxia. (See "Croup: Pharmacologic and
supportive interventions", section on 'Heliox'.)

●Intubation − The need for intubation should be anticipated in children with

progressive respiratory failure so that the procedure can be performed in a
controlled setting if possible. Intubation can be challenging due to the narrowed
subglottic airway and should be performed with the assistance of a skilled provider
(ie, an anesthesiologist or otolaryngologist). Neuromuscular blocking agents
should be avoided unless the ability to provide bag-mask ventilation has been
demonstrated. An endotracheal tube that is 0.5 to 1 mm smaller than would
typically be used should be placed. (See 'Croup severity score' above
and "Emergency endotracheal intubation in children", section on 'Endotracheal
tube'.)

Endotracheal intubation is rarely required for management of croup (<3 percent of

patients in two large retrospective studies) [23,24]. In a retrospective series of 77
children with severe croup requiring intubation, the median duration of mechanical
ventilation was 60 hours, and 6.5 percent of patients required reintubation after
the first attempt at extubation [28]. Of note, the endotracheal cuff leak (which is
commonly used to assess risk of postextubation stridor) poorly predicted
extubation failure in this study. Half of the patients in this series were diagnosed
with bacterial coinfection or superinfection. (See "Extubation management",
section on 'Cuff leak'.)
Repeated corticosteroid dosing — Repeat doses of corticosteroids are not
necessary on a routine basis and may have adverse effects. Moderate to severe
symptoms that persist for more than a few days should prompt investigation for other
causes of airway obstruction. (See "Croup: Pharmacologic and supportive
interventions", section on 'Repeated dosing' and "Croup: Clinical features, evaluation,
and diagnosis", section on 'Differential diagnosis' and "Assessment of stridor in
children".)

Monitoring — Monitoring should include close observation of mental status and

respiratory status, including monitoring for stridor, cyanosis, air entry, and retractions.
Pulse oximetry monitoring is useful to detect hypoxia; however, it is not a sensitive tool
for assessing the severity of croup [22].

Infection control — Children who are admitted to the hospital with croup should be
managed with contact precautions (ie, gown and gloves for contact), particularly if
parainfluenza or respiratory syncytial virus is the suspected etiology. If influenza is
suspected, droplet isolation measures (ie, respiratory mask within three feet) also
should be followed. (See "Infection prevention: Precautions for preventing transmission
of infection".)

Discharge criteria — Children who require hospital admission may be discharged

when they meet the following criteria:

●No stridor at rest

●Normal pulse oximetry in room air

●Good air exchange

●Normal color

●Normal level of consciousness

●Demonstrated ability to tolerate fluids by mouth

Atypical course — Children admitted for croup typically remain in the hospital for <36
hours [23,25]. The child who does not show improvement as expected (over the course
of one to two days) may have an underlying airway abnormality or may be developing a
complication of croup. Further evaluation with radiographs of the soft tissues of the
neck or consultation with otolaryngology may be warranted. A biphasic illness with poor
response to nebulized epinephrine in conjunction with high fever and toxic appearance
should prompt consideration of bacterial tracheitis (picture 1) [3]. (See "Croup: Clinical
features, evaluation, and diagnosis", section on 'Differential diagnosis' and "Bacterial
tracheitis in children: Clinical features and diagnosis".)

FOLLOW-UP — Any patient who was admitted to the hospital, received

nebulized epinephrine, or had a prolonged outpatient visit should have follow-up
scheduled with the primary care provider within 24 hours or as soon as can be
arranged. Although some children may continue to have mild to moderate symptoms at
the time of follow-up, the available evidence does not support routine use of
corticosteroid therapy beyond 24 hours.

Follow-up should continue until the child's symptoms have begun to resolve. The child
whose symptoms do not resolve over the course of approximately seven days may
have an underlying airway abnormality or may be developing a complication of croup.
(See 'Atypical course' above.)

PROGNOSIS — Symptoms of croup resolve in most children within three days but may
persist for up to one week [23,29,30]. Approximately 8 to 15 percent of children with
croup require hospital admission [20,31], and among those, <3 percent require
intubation [23,24]. Mortality is rare, occurring in <1 percent of intubated children
[23,32].

Complications — Complications of croup are uncommon. Children with moderate to

severe croup are at risk for hypoxemia (oxygen saturation <92 percent in room air) and
respiratory failure. Other complications include pulmonary edema, pneumothorax, and
pneumomediastinum [33]. These complications can be anticipated and managed by
aggressive monitoring and intervention in the medical setting. Out-of-hospital cardiac
arrest and death also have been reported [34].

Secondary bacterial infections may arise from croup. Bacterial tracheitis,

bronchopneumonia, and pneumonia occur in a small number of patients [6,30,35,36].
In most instances, the child has been relatively stable or beginning to improve after
several days of illness, but then suddenly worsens, with higher or recurrent fever,
increased (and potentially productive) cough, and/or respiratory distress.
(See "Bacterial tracheitis in children: Clinical features and diagnosis", section on
'Clinical features' and "Community-acquired pneumonia in children: Clinical features
and diagnosis", section on 'Clinical presentation'.)

Recurrent symptoms — Approximately 5 percent of children treated for croup in the

outpatient setting have repeat visits for recurrent symptoms within seven days following
discharge [20,23]. Children who have recurrent episodes of classic viral croup may
require radiographic evaluation or bronchoscopy to evaluate for underlying airway
abnormalities. Recurrent episodes of croup-like symptoms occurring outside the typical
age range for "viral croup" (ie, six months to three years) and recurrent episodes that
do not appear to be simple "spasmodic croup" should raise suspicion for large airway
lesions, gastroesophageal reflux or eosinophilic esophagitis, or atopic conditions [37-
42]. (See "Assessment of stridor in children" and "Croup: Clinical features, evaluation,
and diagnosis", section on 'Spasmodic croup'.)

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored

guidelines from selected countries and regions around the world are provided
separately. (See "Society guideline links: Croup".)

INFORMATION FOR PATIENTS — UpToDate offers two types of patient education

materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces
are written in plain language, at the 5th to 6th grade reading level, and they answer the
four or five key questions a patient might have about a given condition. These articles
are best for patients who want a general overview and who prefer short, easy-to-read
materials. Beyond the Basics patient education pieces are longer, more sophisticated,
and more detailed. These articles are written at the 10th to 12th grade reading level and
are best for patients who want in-depth information and are comfortable with some
medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage
you to print or email these topics to your patients. (You can also locate patient
education articles on a variety of subjects by searching on "patient info" and the
keyword[s] of interest.)

●Basics topics (see "Patient education: Croup (The Basics)")

●Beyond the Basics topics (see "Patient education: Croup in infants and children
(Beyond the Basics)")

SUMMARY AND RECOMMENDATIONS

●Management of children with croup begins with an assessment of severity (table

1) (calculator 1). This can be accomplished via telephone triage or in the office or
emergency department setting. If concerns arise on telephone triage (eg, stridor at
rest, an underlying airway abnormality, previous episodes of moderate to severe
croup, underlying conditions that may predispose to respiratory failure, rapid
progression of symptoms, inability to tolerate fluids, prolonged symptoms, or an
atypical course), the child should be seen in the office or emergency department.
(See 'Telephone triage' above.)

●Management of croup is based on the severity of symptoms (algorithm

1 and table 1) (calculator 1):

•Mild croup – Children with mild symptoms (ie, no stridor at rest and no
respiratory distress) can be managed at home. Families should be instructed
in provision of supportive care and indications to seek medical attention. For
children with mild croup who are seen in the outpatient setting, we suggest a
single dose of dexamethasonerather than supportive care alone (algorithm 1)
(Grade 2B). In this setting, the appropriate dose of dexamethasone is 0.15 to
0.6 mg/kg (maximum 16 mg) given orally. Nonpharmacologic management is
a reasonable alternative, particularly if the family has concerns about side
effects from glucocorticoids. (See 'Mild croup' above and "Croup:
Pharmacologic and supportive interventions", section on 'Dexamethasone'.)

•Moderate to severe croup – Children with moderate croup (ie, stridor at

rest with mild to moderate retractions) should be evaluated in the office or
emergency department, and those with severe croup (stridor at rest with
marked retractions and significant distress or agitation) should be evaluated
in the emergency department. Children with severe croup must be
 approached cautiously, as any increase in anxiety may worsen airway
obstruction. (See 'Moderate to severe croup' above.)

-For children with moderate to severe croup, we recommend initial

treatment with nebulized epinephrine and a single dose
of dexamethasone rather than either drug alone or nonpharmacologic
management (Grade 1B). (See 'Initial treatment' above.)

-Dexamethasone is given at a dose of 0.6 mg/kg (maximum of 16 mg)

by the least invasive route (algorithm 1). Dosing of
nebulized epinephrine depends on the product used. Racemic
epinephrine is administered as 0.05 mL/kg per dose (maximum of 0.5
mL) of a 2.25 percent solution diluted to 3 mL total volume with normal
saline. L-epinephrine is administered as 0.5 mL/kg per dose (maximum
of 5 mL) of a 1:1000 dilution. In both cases, it is given via nebulizer over
15 minutes. (See "Croup: Pharmacologic and supportive interventions",
section on 'Dexamethasone' and "Croup: Pharmacologic and supportive
interventions", section on 'Nebulized epinephrine'.)

-Nebulized epinephrine can be repeated every 15 to 20 minutes. The

administration of three or more doses within a two- to three-hour time
period should prompt initiation of close cardiac monitoring if this is not
already underway.

-We suggest not routinely using repeated doses of corticosteroids

(Grade 2C). (See 'Repeated corticosteroid dosing' above and "Croup:
Pharmacologic and supportive interventions", section on 'Repeated
dosing'.)

-Children with moderate to severe croup should be observed for three to

four hours after intervention. Those who improve may be discharged
home. Children with persistent or worsening symptoms during the
observation period should be admitted to the hospital. (See 'Discharge
to home' above and 'Indications for hospital admission' above.)

•Hospital management – Management of children hospitalized for croup

includes (see 'Inpatient management' above):

-Supportive care with provision of intravenous fluids and fever reduction

(see 'Supportive care' above)

-Respiratory care with repeated doses of nebulized epinephrine, as

indicated by respiratory distress, and administration of humidified air or
oxygen, as indicated by hypoxemia (see 'Respiratory care' above)

-Monitoring for worsening respiratory distress (see 'Monitoring' above)

●Children who have moderate to severe symptoms that persist for more than a
few days or recurring episodes of croup not associated with other manifestations
of a viral illness (no fever and/or rhinorrhea) should undergo investigation for other
causes of upper airway obstruction. (See 'Atypical course' above and 'Recurrent
symptoms' above and "Croup: Clinical features, evaluation, and diagnosis",
section on 'Differential diagnosis'.)

●Most children with croup recover uneventfully. Children who received

nebulized epinephrine, had a prolonged outpatient visit, or were admitted to the
hospital should have follow-up scheduled with the primary care provider within 24
hours of discharge or as soon as follow-up can be arranged. (See 'Follow-
up' above and 'Prognosis' above.)

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REFERENCES