Max 8 mg/dose · Duration: Once · 0.15 mg/kg PO once (max 8 mg) — first-line per NICE NG51; noninferior to 0.6 mg/kg in large RCT (Gates 2018)
• Dexamethasone indications (AAP/NICE/CPS): give to **all children with clinically significant croup** — barky cough with stridor and/or respiratory distress; includes mild croup presenting to ED/outpatient; NOT indicated for isolated barky cough without stridor in well child at home (NICE NG51, AAP, CPS).
• Standard higher dose option: **0.6 mg/kg** PO/IM/IV once (max 10–12 mg per CPS/AAP/AFP 2026) — historically most-studied dose; meta-analysis suggests possible added benefit in **severe** disease; 0.15 mg/kg equally effective in most RCTs (CPS, StatPearls, AFP 2026).
• Route preference: **oral PO preferred** — equal or superior to nebulized budesonide; less vomiting than prednisolone in some studies; IM or IV same mg/kg dose when persistent vomiting or unable to tolerate PO (CPS, NICE NG51, Calgary Croup Guideline).
• Single dose usually sufficient — repeat dexamethasone only if clinical deterioration or per local protocol (Calgary: case-by-case q12–24 h); do NOT withhold steroids awaiting radiology (NICE NG51).
• Differential diagnosis: exclude epiglottitis (toxic, drooling, no cough, tripod), bacterial tracheitis (high fever, toxic, poor steroid response), retropharyngeal abscess, angioedema/anaphylaxis, foreign body — do not examine oropharynx if epiglottitis suspected (AAP, NICE NG51, ERC airway principles).
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Prednisolone • p.o. • 1–1 mg/kg/dose • 1×/day
Max 50 mg/dose · Duration: Once · 1 mg/kg PO once (max 50 mg) — use when dexamethasone unavailable; some centers use 1–3 daily doses for moderate disease (NICE NG51)
• Prednisolone: dexamethasone unavailable or local formulary restriction — 1 mg/kg PO once (max 50 mg) per NICE NG51; equivalent clinical improvement within 4–6 h.
• Dexamethasone 0.6 mg/kg: CPS and many North American centers use 0.6 mg/kg as standard — consider when Westley score ≥5 or local protocol mandates higher dose (CPS, AFP 2026).
• IM/IV dexamethasone: persistent vomiting after PO attempt, severe respiratory distress, or nil-by-mouth — same mg/kg as oral (0.15 or 0.6 mg/kg per protocol) (CPS, Calgary).
• Home care (mild croup): cool mist/humidified air, antipyretics, fluids, caregiver education on warning signs — return if stridor at rest, increased work of breathing, cyanosis, or fatigue (NICE NG51, AAP).
• Antibiotics NOT indicated for uncomplicated viral croup — reserve for suspected bacterial tracheitis or secondary bacterial infection (AAP, NICE NG51).
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Clinical notes
• Severity assessment: use **Westley Croup Score** (0–17) and clinical features — **mild** (≤2): barky cough, no/minimal stridor at rest; **moderate** (3–5): stridor at rest, mild chest recession, SpO₂ ≥95%; **severe** (6–11): prominent stridor, marked recession, agitation, SpO₂ <95%; **impending failure** (≥12): lethargy, pallor/cyanosis, exhaustion — reassess after each intervention (NICE NG51, StatPearls, Westley 1978).
• Dexamethasone indications: AAP and NICE recommend corticosteroids for **all clinically significant croup** (barky cough with stridor ± distress) — including mild cases presenting to ED; reduces return visits, hospitalization, and need for nebulized epinephrine; give as soon as diagnosis made, do not delay for imaging (NICE NG51, AAP, CPS).
• Nebulized epinephrine/adrenaline: **NOT** for mild croup — reserve for **moderate–severe** croup with stridor at rest, hypoxia (SpO₂ <95%), marked recession, or failure to improve after dexamethasone; clinical improvement expected within 10–30 min; poor response → admit (NICE NG51, CPS, AAP).
• Observation after nebulized epinephrine: minimum **2–4 hours** (NICE: up to 4 h; CPS: rebound stridor may occur after ~2 h) before discharge — monitor for biphasic worsening; do not discharge if stridor at rest persists, SpO₂ <95%, or parental concern (NICE NG51, CPS, StatPearls).
• Oxygen targets: give humidified O₂ if **SpO₂ <95%** or significant respiratory distress — target **SpO₂ ≥95%** (NICE NG51); ERC pediatric resuscitation: titrate supplemental O₂ to correct hypoxemia, avoid hyperoxia when stable. **Hospital admission**: moderate–severe croup after epinephrine, persistent stridor at rest, hypoxia, dehydration, age <6 months, or social concerns. **ICU/airway specialist**: impending respiratory failure (Westley ≥12), exhaustion, cyanosis, severe hypoxia despite O₂, altered consciousness, drooling with epiglottitis concern, or need for advanced airway — urgent anesthesia/ENT (NICE NG51, CPS, ERC).
• AAP Clinical Practice Guideline — Diagnosis and Management of Croup (2011)
• AAP Red Book — Parainfluenza viral infections / croup (2024)
• NICE NG51 — Croup (assessment and management) (2017)
+ 5 more
• CPS — Acute management of croup in the emergency department (2021)
• BTS/SIGN — British Guideline on the Management of Asthma (corticosteroid and nebulized therapy principles) (2024)
• ERC — European Resuscitation Council Guidelines (pediatric airway and oxygen) (2021)
• Cochrane — Glucocorticoids for croup in children (2022)
