Acute laryngotracheobronchitis (croup) is the most common cause of airway obstruction in children. This illness is managed with cool-mist therapy, nebulized racemic epinephrine and steroids. Steroids have been shown to improve croup scores and decrease the need for further treatment and hospitalization. Rittichier and Ledwith conducted this single-blind, prospective study to determine whether oral or intramuscular (IM) dexamethasone was more effective in treating patients with moderate croup.
Children who were diagnosed with moderate croup in the emergency department were included if they were three months to 12 years of age and had been sick for less than 48 hours. Any children admitted to the hospital during the initial visit were excluded from the study. After evaluation (including assigning a pretreatment score), cool-mist treatments were administered to all patients. The attending physicians were able to provide nebulized racemic epinephrine and antibiotics on admission at their discretion. Patients were randomized to receive either 0.6 mg per kg of oral (crushed tablet, not liquid) or IM dexamethasone. A post-treatment croup score was determined at discharge. Caretakers were contacted by telephone between 48 and 72 hours after discharge to determine the child's current clinical status. Caregivers were asked to assess their child's clinical status in terms of the symptoms being worse than, the same as or better than initial symptoms, or whether all symptoms were resolved. The primary outcome was need for treatment other than that provided in the emergency department.
There were 277 patients who met the final inclusion criteria and were evaluated for this study. IM and oral dexamethasone were administered to 139 and 138 children, respectively. Eighty patients (29 percent) returned for further treatment, with slightly more in the IM group than in the oral group. Twenty-three children required more steroids, five required more nebulized racemic epinephrine and four required hospitalization. Evaluation of the caregivers' reports showed that symptoms were completely resolved in 48 percent of the patients who received oral dexamethasone and in 54 percent of the patients who received IM dexamethasone. Improvement was seen in 42 percent of the IM group and in 47 percent of the patients in the oral group. These differences between groups were not statistically significant.
The authors conclude that oral dexamethasone is as effective as IM dexamethasone in patients with moderate croup and avoids the anxiety and pain associated with IM injections. In children who cannot tolerate the oral medication, IM delivery remains a useful option.