Croup is a common pediatric respiratory condition that occurs most often in children younger than six years. Many children with croup present to the emergency department and ultimately require hospital admission. Several studies have found that the use of glucocorticoids may result in significant clinical improvement in children with this viral illness. Johnson and colleagues performed a randomized, double-blind, placebo-controlled trial to determine whether the administration of steroids to children with moderately severe croup would decrease their need for hospitalization.
Children enrolled in the study were between the ages of three months and nine years and were seen at one of two hospital emergency departments. All of the study subjects presented with acute onset of respiratory stridor associated with a barking cough and had persistent respiratory distress after treatment with humidified oxygen for 30 minutes. A croup scoring system was used that assessed degree of stridor, retractions, air entry, cyanosis and level of consciousness. Children with symptoms or signs suggestive of epiglottitis, bacterial tracheitis or supraglottic foreign body were excluded from the study. A history of recent steroid use, chronic pulmonary disease or immune dysfunction were also exclusion criteria.
Eligible children were randomized to receive intramuscular dexamethasone (0.6 mg per kg), a single dose of nebulized budesonide (4.0 mg) or placebo. All patients received racepinephrine plus saline combined with budesonide or placebo via nebulizer. The nebulized study drugs were identical in appearance. A placebo injection was not used, but all children were briefly separated from their parents and had a bandage placed on the thigh to maintain the masking component of the study. Racepinephrine was given as needed. The children were assessed hourly for five hours after treatment and then were discharged or admitted to the hospital. The parents of children who were sent home from the emergency department were followed by telephone 72 hours after discharge to assess the need for reevaluation.
A total of 4,075 children with a diagnosis of croup were seen during the enrollment period. After exclusion criteria were applied and parental consent was obtained, 145 children were randomized into the three groups. The baseline characteristics, including duration of symptoms, oxygen saturation and croup scores, did not differ significantly between groups. In the placebo group, 67 percent of children were hospitalized, compared with 35 percent in the budesonide group and 17 percent in the dexamethasone group. The study was terminated early because of the significant differences in rates of hospitalization among the groups. Patients were reassessed by study nurses and physicians, who found the mean changes in croup scores to be significantly greater in the two treatment groups. Sixteen children in the placebo group received additional racepinephrine treatments, compared with nine in the budesonide group and four in the dexamethasone group. No gastrointestinal bleeding or bacterial tracheitis was noted.
The authors conclude that the treatment of croup with glucocorticoids produces rapid clinical improvement and significantly reduces the rate of hospitalization. Treatment with intramuscular dexamethasone appears to offer the most benefit.
editor's note: This study contributes to a growing body of literature showing corticosteroids to be very effective in treating croup. This effect is apparent in children with mild, moderate or severe symptoms. Nebulized budesonide is not currently available in this country, but many emergency department settings have adopted a protocol of using intramuscular dexamethasone at a standard dosage of 0.6 mg per kg. In children with mild croup, data support the use of oral dexamethasone (0.6 mg per kg), which can easily be given at a physician's office without nebulized epinephrine.—j.t.k.