Patients presenting with mild croup without stridor or chest wall retractions should be treated with oral dexamethasone. These children can then be safely discharged home without further observation if parents appear reliable and adequate key information is provided to them.6,54 Parents should be educated on the anticipated course of illness, signs of respiratory distress and, most importantly, when to seek medical care. (See Figure 2.)
Children with moderate croup who are experiencing stridor and signs of respiratory distress (such as chest wall retractions) but who do not have any alteration in their level of consciousness should also be treated with oral dexamethasone and nebulized epinephrine. These children should be observed for a minimum of 2 to 4 hours following the treatment with epinephrine. If the child has improved and no longer shows signs of upper airway obstruction at the end of the observation period, he or she may be safely discharged home, provided the caregivers are reliable and able to return to the hospital should the symptoms recur.52
Hospital admission should be considered in cases of moderate to severe croup where patients have not improved after 4 hours of observation or who have a poor response to epinephrine. Consultation with a pediatric ICU or anesthesia is critical if a child exhibits signs of impending respiratory failure or recurrent episodes of agitation or lethargy that are not improving with nebulized epinephrine. Children with croup do not need specific follow-up. If stridor persists for over a week without any signs of respiratory distress, parents should see their primary care provider who can decide to further refer to an otolaryngologist to rule out other causes of stridor.