Indication (Clinically significant croup — barky cough with stridor and/or respiratory distress; give to all children presenting with moderate symptoms; aligns with **Croup** card (NICE NG51, AAP, CPS))
Max 8 mg/dose · Duration: Once · 0.15 mg/kg once (max 8 mg) — first-line per NICE NG51; noninferior to 0.6 mg/kg (Gates 2018)
• Standard dose: **0.15 mg/kg** PO/IM/IV once (max **8 mg**) — NICE NG51 preferred; RCT noninferior to 0.6 mg/kg for mild–moderate croup (Gates 2018, Cochrane CD006879).
• Higher dose option: **0.6 mg/kg** PO/IM/IV once (max **10–12 mg** per CPS/AAP) — historically most-studied dose; meta-analysis suggests possible added benefit in **severe** disease; use when local protocol mandates or severe Westley score (CPS, AAP, AFP 2026).
• Indications: give to **all children with clinically significant croup** presenting to ED/outpatient — barky cough with stridor and/or respiratory distress; NOT for isolated barky cough without stridor in well child at home (NICE NG51, AAP, CPS).
• Repeat dosing: single dose usually sufficient — repeat dexamethasone only if clinical deterioration (case-by-case q12–24 h per Calgary); avoid unnecessary repeat doses (NICE NG51, Calgary Croup Guideline).
• Differential: exclude epiglottitis, bacterial tracheitis, retropharyngeal abscess, angioedema/anaphylaxis, foreign body — do not examine oropharynx if epiglottitis suspected (AAP, NICE NG51).
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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) — equivalent to dexamethasone for croup
• When dexamethasone unavailable or locally preferred — prednisolone 1 mg/kg single dose equivalent for croup (NICE NG51, Cochrane CD006879).
• Nebulized budesonide 2 mg once — alternative in some settings when oral steroids not tolerated; dexamethasone PO generally preferred (NICE NG51, CPS).
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Clinical notes
• Single dose usually sufficient for croup — repeat only if clinical deterioration; aligns with **Croup** card Westley severity pathway (NICE NG51, AAP, CPS).
• PO route preferred; IM/IV when vomiting or unable to take oral — same mg/kg dose regardless of route (NICE NG51, CPS).
• Short-course adverse effects: hyperglycaemia, mood/behavioural changes, GI upset — generally mild with single dose; counsel caregivers (BNFC, AAP).
• Contraindications: systemic fungal infection; caution in varicella if immunocompromised; live vaccine timing considerations with prolonged courses (not relevant for single dose) (BNFC, AAP Red Book).
• Always co-administer with nebulized epinephrine when indicated for moderate–severe croup — observe 2–4 h after nebulized epinephrine (NICE NG51, AAP).
