A 3-year-old child presents with inspiratory stridor, fever, and a barking cough that worsened at night. X-ray neck AP view shows the 'steeple sign' (subglottic narrowing). The MOST appropriate pharmacological first-line treatment is:

• A Intravenous dexamethasone 0.15–0.6 mg/kg single dose
• B Nebulised adrenaline (epinephrine) 0.5 mg/kg (max 5 mg) in normal saline
• C Oral prednisolone 1 mg/kg for 3 days
• D Inhaled budesonide 2 mg nebulised, with or without nebulised adrenaline for moderate-severe croup ✓

Explanation

Current evidence-based guidelines for moderate-to-severe croup (laryngotracheobronchitis) recommend nebulised budesonide 2 mg as effective as oral dexamethasone for rapid symptom relief, and nebulised epinephrine (adrenaline) 0.5 mL/kg of 1:1000 solution (max 5 mL) provides short-term relief of severe obstruction. Dexamethasone 0.6 mg/kg oral or IM single dose remains the gold standard systemic steroid for all grades of croup; however for moderate-severe cases the combination of nebulised budesonide plus nebulised adrenaline is first-line in-hospital management. Oral prednisolone is less preferred over dexamethasone due to inferior evidence.

Reference: Dhingra Diseases of Ear, Nose and Throat, 7th ed.

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Written and medically reviewed by the StethoPrep medical team.