Is it typical croup?
Typical croup is a barky cough, hoarse voice and inspiratory stridor, often at night, usually between 6 months and 3 years, after a cold. Drooling, a toxic look, high fever, no barky cough, sudden onset with choking, age under 6 months or recurrent episodes point to other causes.
- Epiglottitis: toxic, drooling, tripod position, no barky cough; airway team in the operating room and no throat exam
- Bacterial tracheitis: high fever, toxic, poor response to epinephrine
- Foreign body: sudden choking onset
- Retropharyngeal or peritonsillar abscess: neck stiffness, trismus
- Anaphylaxis or angioedema: hives, swelling, exposure
- Under 6 months or recurrent croup: airway evaluation for subglottic stenosis or hemangioma
Grading severity
The calculator uses a Westley-based grading in four levels.
- Mild: occasional barky cough, no stridor at rest, no or mild retractions
- Moderate: frequent cough, stridor at rest, retractions, little or no agitation
- Severe: stridor at rest, marked retractions, agitation or distress
- Impending respiratory failure: fatigue, decreasing consciousness, cyanosis, a quiet chest despite distress
Dexamethasone and other steroids
Give dexamethasone 0.6 mg/kg once by mouth (or IM), maximum 16 mg. For mild croup, a dose anywhere from 0.15 to 0.6 mg/kg works, and steroids reduce return visits even in mild cases. If dexamethasone is unavailable, prednisolone 1 to 2 mg/kg once by mouth is an alternative. If vomiting prevents an oral steroid, nebulized budesonide 2 mg as a single dose can be used. A second dose of dexamethasone is rarely needed.
Nebulized epinephrine
Moderate and severe croup also get nebulized epinephrine. Racemic epinephrine 2.25% is 0.05 mL/kg in 3 mL saline, maximum 0.5 mL, and may be repeated every 15 to 20 minutes. L-epinephrine 1 mg/mL (1:1,000) at 0.5 mL/kg, maximum 5 mL, is an equivalent alternative.
| Weight | Dexamethasone 0.6 mg/kg | Dexamethasone 0.15 mg/kg (mild) | Racemic epinephrine 2.25% | L-epinephrine 1 mg/mL |
|---|---|---|---|---|
| 5 kg | 3 mg | 0.75 mg | 0.25 mL | 2.5 mL |
| 10 kg | 6 mg | 1.5 mg | 0.5 mL | 5 mL |
| 15 kg | 9 mg | 2.25 mg | 0.5 mL (max) | 5 mL (max) |
| 20 kg | 12 mg | 3 mg | 0.5 mL (max) | 5 mL (max) |
| 25 kg | 15 mg | 3.75 mg | 0.5 mL (max) | 5 mL (max) |
| 30 kg | 16 mg (max) | 4.5 mg | 0.5 mL (max) | 5 mL (max) |
Going home or staying
After epinephrine, observe the child. Discharge if there is no stridor at rest 2 to 4 hours after the last epinephrine dose. Admit if stridor at rest returns or 2 or more doses were needed.
On the ward, repeat epinephrine as needed and move to intensive care if it is needed more often than every 1 to 2 hours. Give oxygen if SpO2 is under 92%, and look for another diagnosis if there is no improvement.
Impending respiratory failure
Give nebulized epinephrine and dexamethasone at once, call the airway team and arrange intensive care. Prepare for intubation with a tube 0.5 mm smaller than usual for age. Give oxygen, keep the child calm with a parent, and repeat epinephrine as needed. Heliox (70:30) may buy time if available.
Advice for families
Most croup improves in 2 to 3 days and is worse at night. Keep the child calm and upright; cool night air may soothe, while mist has no proven benefit. Return at once for stridor at rest, retractions, drooling, blue color or exhaustion.
Use the free tool
Severity, dexamethasone and nebulized epinephrine doses, observation and admission.
Open Croup →Common questions
What is the dexamethasone dose for croup?
0.6 mg/kg once by mouth or IM, maximum 16 mg. For mild croup, 0.15 mg/kg also works.
Does mild croup need a steroid?
Yes. A single dose of oral dexamethasone reduces return visits even in mild croup.
How long should a child be watched after nebulized epinephrine?
The child can go home if there is no stridor at rest 2 to 4 hours after the last epinephrine dose. Persistent stridor at rest, or needing 2 or more doses, means admission.
What if the child vomits the oral steroid?
Nebulized budesonide 2 mg as a single dose is an option when vomiting prevents an oral steroid.
Sources
Bjornson CL, Johnson DW. Croup in children. CMAJ 2013;185:1317-1323.; Gates A, et al. Glucocorticoids for croup in children. Cochrane Database Syst Rev 2018.; Bjornson C, et al. Nebulized epinephrine for croup in children. Cochrane Database Syst Rev 2013.; Westley CR, et al. Am J Dis Child 1978;132:484-487.
For education only, not medical advice. Always confirm against current guidelines and your local protocols. Pedemy is independent and not affiliated with or endorsed by the organizations cited.