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Croup: Pharmacologic and supportive interventions

Charles R Woods, MD, MS
Section Editors
Sheldon L Kaplan, MD
Anna H Messner, MD
Deputy Editor
Carrie Armsby, MD, MPH


Croup (laryngotracheitis) is a respiratory illness characterized by inspiratory stridor, barking cough, and hoarseness. It typically occurs in children six months to three years of age and most commonly is caused by parainfluenza virus. (See "Croup: Clinical features, evaluation, and diagnosis".)

The treatment of croup has changed significantly since the 1980s. Glucocorticoids and nebulized epinephrine have become the cornerstones of therapy. Substantial clinical evidence supports the efficacy of these interventions [1-5]. The impact also is evident in the decrease in annual hospital admissions for croup in children in the United States between 1979 to 1982 and 1994 to 1997 (from 2.8 to 2.1 per 1000 for children <1 year and from 1.8 to 1.2 per 1000 children for children 1 to 4 years) [6].

Treatment of croup may involve a variety of pharmacologic and nonpharmacologic interventions. It may occur entirely at home, or in the office, emergency department, or hospital setting. Supportive and pharmacologic interventions will be discussed below. The clinical features and evaluation of croup and the approach to management are discussed separately. (See "Croup: Clinical features, evaluation, and diagnosis" and "Croup: Approach to management".)


Glucocorticoids provide long-lasting and effective treatment of mild, moderate, and severe croup [3,7-9]. The anti-inflammatory actions of glucocorticoids are thought to decrease edema in the laryngeal mucosa of children with croup. Improvement is usually evident within six hours of administration but seldom is dramatic [7,10].

Treatment with glucocorticoids at various doses and by various routes has been shown to improve croup scores and to decrease unscheduled medical visits, length of stay in the emergency department (ED) or hospital, and the use of epinephrine [7]. Among the available glucocorticoids, dexamethasone has been used most frequently, is the least expensive, has the longest duration of action, and is the easiest to administer.

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Literature review current through: Sep 2017. | This topic last updated: Aug 24, 2017.
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  1. Westley CR, Cotton EK, Brooks JG. Nebulized racemic epinephrine by IPPB for the treatment of croup: a double-blind study. Am J Dis Child 1978; 132:484.
  2. Fogel JM, Berg IJ, Gerber MA, Sherter CB. Racemic epinephrine in the treatment of croup: nebulization alone versus nebulization with intermittent positive pressure breathing. J Pediatr 1982; 101:1028.
  3. Kairys SW, Olmstead EM, O'Connor GT. Steroid treatment of laryngotracheitis: a meta-analysis of the evidence from randomized trials. Pediatrics 1989; 83:683.
  4. Johnson DW, Jacobson S, Edney PC, et al. A comparison of nebulized budesonide, intramuscular dexamethasone, and placebo for moderately severe croup. N Engl J Med 1998; 339:498.
  5. Klassen TP, Feldman ME, Watters LK, et al. Nebulized budesonide for children with mild-to-moderate croup. N Engl J Med 1994; 331:285.
  6. Counihan ME, Shay DK, Holman RC, et al. Human parainfluenza virus-associated hospitalizations among children less than five years of age in the United States. Pediatr Infect Dis J 2001; 20:646.
  7. Russell KF, Liang Y, O'Gorman K, et al. Glucocorticoids for croup. Cochrane Database Syst Rev 2011; :CD001955.
  8. Tibballs J, Shann FA, Landau LI. Placebo-controlled trial of prednisolone in children intubated for croup. Lancet 1992; 340:745.
  9. Bjornson CL, Klassen TP, Williamson J, et al. A randomized trial of a single dose of oral dexamethasone for mild croup. N Engl J Med 2004; 351:1306.
  10. Geelhoed GC, Macdonald WB. Oral and inhaled steroids in croup: a randomized, placebo-controlled trial. Pediatr Pulmonol 1995; 20:355.
  11. Klassen TP, Craig WR, Moher D, et al. Nebulized budesonide and oral dexamethasone for treatment of croup: a randomized controlled trial. JAMA 1998; 279:1629.
  12. Geelhoed GC. Budesonide offers no advantage when added to oral dexamethasone in the treatment of croup. Pediatr Emerg Care 2005; 21:359.
  13. Griffin S, Ellis S, Fitzgerald-Barron A, et al. Nebulised steroid in the treatment of croup: a systematic review of randomised controlled trials. Br J Gen Pract 2000; 50:135.
  14. Fernandes RM, Oleszczuk M, Woods CR, et al. The Cochrane Library and safety of systemic corticosteroids for acute respiratory conditions in children: an overview of reviews. Evid Based Child Health 2014; 9:733.
  15. Johnson D. Croup. Clin Evid 2005; :310.
  16. Vernacchio L, Mitchell AA. Oral dexamethasone for mild croup. N Engl J Med 2004; 351:2768.
  17. Cherry JD. Croup (laryngitis, laryngotracheitis, spasmodic croup, laryngotracheobronchitis, bacterial tracheitis, and laryngotracheobronchopneumonitis) and epiglottitis (supraglottitis). In: Feigin and Cherry’s Textbook of Pediatric Infectious Diseases, 7th ed, Cherry JD, Harrison GJ, Kaplan SL, et al (Eds), Elsevier Saunders, Philadelphia 2014. p.241.
  18. Johnson DW, Schuh S, Koren G, Jaffee DM. Outpatient treatment of croup with nebulized dexamethasone. Arch Pediatr Adolesc Med 1996; 150:349.
  19. Kaditis AG, Wald ER. Viral croup: current diagnosis and treatment. Pediatr Infect Dis J 1998; 17:827.
  20. Dowell SF, Bresee JS. Severe varicella associated with steroid use. Pediatrics 1993; 92:223.
  21. Kiff KM, Mok Q, Dunne J, Tasker RC. Steroids for intubated croup masking airway haemangioma. Arch Dis Child 1996; 74:66.
  22. Alberta Clinical Practice Guideline WorkingGroup. Guideline for the diagnosis and management of croup. 2008. www.topalbertadoctors.org/download/252/croup_guideline.pdf (Accessed on October 31, 2013).
  23. Luria JW, Gonzalez-del-Rey JA, DiGiulio GA, et al. Effectiveness of oral or nebulized dexamethasone for children with mild croup. Arch Pediatr Adolesc Med 2001; 155:1340.
  24. Geelhoed GC, Turner J, Macdonald WB. Efficacy of a small single dose of oral dexamethasone for outpatient croup: a double blind placebo controlled clinical trial. BMJ 1996; 313:140.
  25. Geelhoed GC, Macdonald WB. Oral dexamethasone in the treatment of croup: 0.15 mg/kg versus 0.3 mg/kg versus 0.6 mg/kg. Pediatr Pulmonol 1995; 20:362.
  26. Fifoot AA, Ting JY. Comparison between single-dose oral prednisolone and oral dexamethasone in the treatment of croup: a randomized, double-blinded clinical trial. Emerg Med Australas 2007; 19:51.
  27. Alshehr M, Almegamsi T, Hammdi A. Efficacy of a small dose of oral dexamethasone in croup. Biomed Res 2005; 16:65.
  28. Paul RI. Oral dexamethasone for croup (commentary). AAP Grand Rounds 2004; 12:67.
  29. Duggan DE, Yeh KC, Matalia N, et al. Bioavailability of oral dexamethasone. Clin Pharmacol Ther 1975; 18:205.
  30. Cetinkaya F, Tüfekçi BS, Kutluk G. A comparison of nebulized budesonide, and intramuscular, and oral dexamethasone for treatment of croup. Int J Pediatr Otorhinolaryngol 2004; 68:453.
  31. Garbutt JM, Conlon B, Sterkel R, et al. The comparative effectiveness of prednisolone and dexamethasone for children with croup: a community-based randomized trial. Clin Pediatr (Phila) 2013; 52:1014.
  32. Sparrow A, Geelhoed G. Prednisolone versus dexamethasone in croup: a randomised equivalence trial. Arch Dis Child 2006; 91:580.
  33. Connors K, Gavula D, Terndrup T. The use of corticosteroids in croup: a survey. Pediatr Emerg Care 1994; 10:197.
  34. Amir L, Hubermann H, Halevi A, et al. Oral betamethasone versus intramuscular dexamethasone for the treatment of mild to moderate viral croup: a prospective, randomized trial. Pediatr Emerg Care 2006; 22:541.
  35. Cherry JD. State of the evidence for standard-of-care treatments for croup: are we where we need to be? Pediatr Infect Dis J 2005; 24:S198.
  36. Kristjánsson S, Berg-Kelly K, Winsö E. Inhalation of racemic adrenaline in the treatment of mild and moderately severe croup. Clinical symptom score and oxygen saturation measurements for evaluation of treatment effects. Acta Paediatr 1994; 83:1156.
  37. Taussig LM, Castro O, Beaudry PH, et al. Treatment of laryngotracheobronchitis (croup). Use of intermittent positive-pressure breathing and racemic epinephrine. Am J Dis Child 1975; 129:790.
  38. Corkey CW, Barker GA, Edmonds JF, et al. Radiographic tracheal diameter measurements in acute infectious croup: an objective scoring system. Crit Care Med 1981; 9:587.
  39. Kuusela AL, Vesikari T. A randomized double-blind, placebo-controlled trial of dexamethasone and racemic epinephrine in the treatment of croup. Acta Paediatr Scand 1988; 77:99.
  40. Bjornson C, Russell K, Vandermeer B, et al. Nebulized epinephrine for croup in children. Cochrane Database Syst Rev 2013; :CD006619.
  41. Waisman Y, Klein BL, Boenning DA, et al. Prospective randomized double-blind study comparing L-epinephrine and racemic epinephrine aerosols in the treatment of laryngotracheitis (croup). Pediatrics 1992; 89:302.
  42. Butte MJ, Nguyen BX, Hutchison TJ, et al. Pediatric myocardial infarction after racemic epinephrine administration. Pediatrics 1999; 104:e9.
  43. Duncan PG. Efficacy of helium--oxygen mixtures in the management of severe viral and post-intubation croup. Can Anaesth Soc J 1979; 26:206.
  44. Terregino CA, Nairn SJ, Chansky ME, Kass JE. The effect of heliox on croup: a pilot study. Acad Emerg Med 1998; 5:1130.
  45. Weber JE, Chudnofsky CR, Younger JG, et al. A randomized comparison of helium-oxygen mixture (Heliox) and racemic epinephrine for the treatment of moderate to severe croup. Pediatrics 2001; 107:E96.
  46. Moraa I, Sturman N, McGuire T, van Driel ML. Heliox for croup in children. Cochrane Database Syst Rev 2013; :CD006822.
  47. Skolnik NS. Treatment of croup. A critical review. Am J Dis Child 1989; 143:1045.
  48. Neto GM, Kentab O, Klassen TP, Osmond MH. A randomized controlled trial of mist in the acute treatment of moderate croup. Acad Emerg Med 2002; 9:873.
  49. Scolnik D, Coates AL, Stephens D, et al. Controlled delivery of high vs low humidity vs mist therapy for croup in emergency departments: a randomized controlled trial. JAMA 2006; 295:1274.
  50. Dulfano MJ, Adler K, Wooten O. Physical properties of sputum. IV. Effects of 100 per cent humidity and water mist. Am Rev Respir Dis 1973; 107:130.
  51. Parks CR. Mist therapy: rationale and practice. J Pediatr 1970; 76:305.
  52. Henry R. Moist air in the treatment of laryngotracheitis. Arch Dis Child 1983; 58:577.
  53. Sasaki CT, Suzuki M. The respiratory mechanism of aerosol inhalation in the treatment of partial airway obstruction. Pediatrics 1977; 59:689.
  54. Fanconi S, Burger R, Maurer H, et al. Transcutaneous carbon dioxide pressure for monitoring patients with severe croup. J Pediatr 1990; 117:701.