Treatment algorithm

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer

ACUTE

mild (no stridor at rest)

1st line – corticosteroid + supportive care

Back
ACUTE
|
mild (no stridor at rest)
1st line – 

corticosteroid + supportive care

A single dose of oral dexamethasone is given as soon as the clinical diagnosis of croup has been made. Its effect in reducing the clinical signs of croup is seen within 2 hours, with further beneficial effects noted up to 10 hours following administration.[38]

Traditionally, a dose of 0.6 mg/kg/dose was used for croup; however, evidence now supports the use of a smaller dose of 0.15 mg/kg/dose.[59]

Care should be taken to avoid frightening the child, as agitation may cause worsening of symptoms.[19] Especially in mild croup, parental assurance and education to the self-limited nature of the illness is important.

Historically mist or humidified air have been widely employed, but there is now convincing evidence that these are ineffective[19][85][86][87][88][89][90]​ and even harmful in some instances.

Primary options

dexamethasone: 0.15 to 0.6 mg/kg orally as a single dose

moderate (stridor at rest; no agitation or lethargy)

1st line – corticosteroid + supportive care

Back
ACUTE
|
moderate (stridor at rest; no agitation or lethargy)
1st line – 

corticosteroid + supportive care

A single dose of oral dexamethasone is given as soon as the clinical diagnosis of croup has been made. Its effect in reducing the clinical signs of croup is seen within 2 hours, with further beneficial effect noted up to 10 hours following administration.[38]

Traditionally, a dose of 0.6 mg/kg/dose was used for croup; however, evidence now supports the use of a smaller dose of 0.15 mg/kg/dose.[59]

Nebulised budesonide is preferable in severe hypoxia, persistent vomiting, or respiratory distress preventing administration of an oral dose.

Intramuscular dexamethasone is another alternative.

Care should be taken to avoid frightening the child, as agitation may cause worsening of symptoms.[19] Historically mist or humidified air have been widely employed, but there is now convincing evidence that these are ineffective[19][85][86][87][88][89][90]​ and even harmful in some instances.

Primary options

dexamethasone: 0.15 to 0.6 mg/kg orally as a single dose

OR

budesonide inhaled: 2 mg nebulised as a single dose

OR

dexamethasone: 0.6 mg/kg intramuscularly as a single dose

Plus – nebulised adrenaline (epinephrine)

Back
ACUTE
|
moderate (stridor at rest; no agitation or lethargy)
Plus – 

nebulised adrenaline (epinephrine)

Treatment recommended for ALL patients in selected patient group

In children presenting with stridor, sternal indrawing at rest, and persistent or increasing agitation, nebulised adrenaline (epinephrine) should be administered in addition to dexamethasone. It provides temporary relief of the airway obstruction while awaiting the effects of corticosteroid treatment.[68] [ Cochrane Clinical Answers logo ]

The clinical effects of nebulised adrenaline (epinephrine) last on average at least 1 hour, but usually subside 2 hours after administration.[34]

The use of one dose at a time of nebulised adrenaline (epinephrine) has not been associated with any clinically significant increases in BP or heart rate, neither has it been associated with any adverse events.[74][79][69][80][81][82][83] Caution should be used with multiple doses of nebulised adrenaline (epinephrine). Careful observation is advisable if adrenaline (epinephrine) treatment is deemed necessary.

Although racemic adrenaline (epinephrine) has traditionally been used to treat children with croup, L-adrenaline (epinephrine) is as effective in moderate to severe croup.[74] In some countries, L-adrenaline (epinephrine) availability may be limited. The same dose is used regardless of weight, as the effective dose of drug delivered to the airway is regulated by individual tidal volume.[75][76][77][78]

Primary options

adrenaline inhaled: (1:1000 solution of L-adrenaline) 5 mL undiluted nebulised as a single dose

OR

adrenaline inhaled: (2.25% racemic solution) 0.5 mL diluted to 2-4 mL with normal saline nebulised as a single dose

severe (stridor at rest with agitation or lethargy)

1st line – corticosteroid + supportive care

Back
ACUTE
|
severe (stridor at rest with agitation or lethargy)
1st line – 

corticosteroid + supportive care

A single dose of oral dexamethasone is given as soon as the clinical diagnosis of croup has been made. Its effect in reducing the clinical signs of croup is seen by 2 hours, with further beneficial effect noted up to 10 hours following administration.[38]

Traditionally, a dose of 0.6 mg/kg/dose was used for croup; however, evidence now supports the use of a smaller dose of 0.15 mg/kg/dose.[59]

Nebulised budesonide is preferable in severe hypoxia, persistent vomiting or respiratory distress preventing administration of an oral dose.

Intramuscular or intravenous dexamethasone is another alternative. However, there is significant potential to increase agitation and respiratory distress when an intravenous line is inserted in a child with severe croup.

Wherever possible, the child should be kept in a calm environment with his/her caregiver. Care should be taken to minimise interventions that would increase the child’s agitation. Historically mist or humidified air have been widely employed, but there is now convincing evidence that these are ineffective[19][85][86][87][88][89][90]​ and even harmful in some instances.

Primary options

dexamethasone: 0.15 to 0.6 mg/kg orally as a single dose

OR

budesonide inhaled: 2 mg nebulised as a single dose

OR

dexamethasone: 0.6 mg/kg intramuscularly as a single dose

Secondary options

dexamethasone: 0.15 to 0.6 mg/kg intravenously as a single dose

Plus – nebulised adrenaline (epinephrine)

Back
ACUTE
|
severe (stridor at rest with agitation or lethargy)
Plus – 

nebulised adrenaline (epinephrine)

Treatment recommended for ALL patients in selected patient group

In children presenting with stridor, sternal/intercostal indrawing at rest, and persistent or increasing agitation, nebulised adrenaline (epinephrine) should be administered in addition to dexamethasone. It provides temporary relief of the airway obstruction while awaiting the effects of corticosteroid treatment.[68] [ Cochrane Clinical Answers logo ]

The clinical effects of nebulised adrenaline (epinephrine) last on average at least 1 hour, but usually subside 2 hours after administration.[34]

The use of one dose at a time of nebulised adrenaline (epinephrine) has not been associated with any clinically significant increases in BP or heart rate; neither has it been associated with any adverse events.[74][79][69][80][81][82][83] Caution should be used with multiple doses of nebulised adrenaline (epinephrine).[84] Careful observation is advisable if adrenaline (epinephrine) treatment is deemed necessary.

Although racemic adrenaline (epinephrine) has traditionally been used to treat children with croup, L-adrenaline (epinephrine) is as effective in moderate to severe croup.[74] In some countries, L-adrenaline (epinephrine) availability may be limited. The same dose is used regardless of weight, as the effective dose of drug delivered to the airway is regulated by individual tidal volume.[75][76][77][78]

Primary options

adrenaline inhaled: (1:1000 solution of L-adrenaline) 5 mL undiluted nebulised as a single dose

OR

adrenaline inhaled: (2.25% racemic solution) 0.5 mL diluted to 2-4mL with normal saline nebulised as a single dose

Plus – supplemental oxygen

Back
ACUTE
|
severe (stridor at rest with agitation or lethargy)
Plus – 

supplemental oxygen

Treatment recommended for ALL patients in selected patient group

Humidified oxygen is given to children demonstrating significant signs and symptoms of respiratory distress, preferably as blow-by oxygen via tubing held a few centimetres from the child's nose and mouth.

In the event that oxygenation is insufficient using this method, 100% oxygen via a non-re-breather mask is administered. However, the application of the mask to the face carries the potential for increasing agitation and preparations (experienced personnel, intubation equipment, medications) should be made to secure the airway if the clinical situation worsens to impending respiratory failure.

Oxygen saturation monitoring should occur, providing this does not increase the child's level of agitation.

Primary options

oxygen: 8 to 10 L/min blow-by

Secondary options

oxygen: 100% by non-re-breather mask

Consider – intubation

Back
ACUTE
|
severe (stridor at rest with agitation or lethargy)
|
with impending respiratory failure
Consider – 

intubation

Additional treatment recommended for SOME patients in selected patient group

Indicated in children progressing to asynchronous chest wall and abdominal movement, fatigue, and signs of hypoxia (pallor or cyanosis) and hypercapnia (decreased level of consciousness secondary to rising PaCO₂).

Becoming increasingly uncommon (in only 1% to 3% of children admitted with croup) and performed as rapid sequence induction in a controlled setting with experienced personnel and equipment.[48][49][50][51]

Advisable to have a selection of endotracheal tubes of smaller sizes at hand, as subglottic oedema may cause difficulty when intubating with a standard sized endotracheal tube.

back arrow

Choose a patient group to see our recommendations

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups. See disclaimer

Use of this content is subject to our disclaimer