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Source: Rittichier KK, Ledwith CA. Outpatient treatment of moderate croup with dexamethasone: Intramuscular versus oral dosing. Pediatrics 2000;106:1344-1348.
Croup (acute laryngotracheobronchitis), commonly caused by viral infection of the upper respiratory tract, results in airway narrowing and a syndrome of barky cough, stridor, and respiratory distress in children. Current management includes cool mist therapy, and nebulized racemic epinephrine in severe cases. There has been a growing body of literature supporting the use of steroids for croup, and demonstrating benefit in terms of severity scores, need for further therapy, and hospitalization. However, the preferred route and dosing of steroids remains controversial. While most studies used intramuscular (IM) dosing, other studies found benefit with oral (PO) as well as nebulized steroids.
This single-blind, randomized study compared PO and IM dosing of dexamethasone (0.6 mg/kg up to a maximum of 8 mg) for children presenting to the emergency department (ED) with moderate croup. Moderate croup was defined as a clinical syndrome of hoarseness and barky cough associated with a history or presence of stridor or retractions. Those with mild croup (no history of stridor or retractions) and severe croup (severe retractions, cyanosis, or altered mental status), as well as those hospitalized on the initial visit were excluded.
Caregivers were contacted 48-72 hours after the initial ED visit to determine subsequent unscheduled return visits (visits to a health care facility or clinic for the same illness) and unscheduled return failures (visits in which the child needed additional treatment, including steroids, racemic epinephrine, and hospitalization), as well as the caregiver’s impression of the child’s symptoms (worse, same, better, or resolved).
During the 33-month study period, 1298 patients were diagnosed with croup, of whom 277 were eligible and randomized to the study (139 children to IM and 138 to PO dosing). There was no statistical difference between the two groups either in terms of unscheduled return visits (32% for the IM group; 25% for the PO group) or unscheduled return failures requiring additional treatment (8% IM vs 9% PO).
In addition, the authors conducted a subgroup analysis of those children with more severe croup (higher croup scores, illness duration < 24 hours, and racemic epinephrine administered on initial ED visit) and still found no difference between the IM and PO groups. Finally, caregivers reported their children’s symptoms improved or resolved in 133 of the IM and 131 of the PO patients. Based on their findings, the authors conclude that oral dosing of dexamethasone in the setting of croup is equally efficacious to IM dosing.
Comment by Theodore C. Chan, MD, FACEP
While the benefit of steroids in the treatment of croup is well-established, the optimal route and dosing remain to be determined. Studies have suggested benefit from parenteral, oral, and even nebulized steroid administration, as well as efficacy at varying doses (such as 0.15-0.6 mg/kg of dexamethasone).1-3
Because of its excellent bioavailability and long half-life, dexamethasone has been studied widely as the steroid of choice for croup. This study is one of the first investigations to compare PO and IM dosing of dexamethasone directly, and it found no difference in terms of clinical efficacy between the two routes.
Practitioners often are reluctant to administer oral medications to sick young children because of tolerability and the potential for vomiting. However, an IM injection causes pain and anxiety, and can worsen stridor in an already croupy, crying child. Injections also are not without risk for both patient and staff. In this study, the investigators crushed dexamethasone tablets into syrup and jelly, rather than using the liquid formulation. The authors reported only one episode of vomiting in a child who later tolerated a repeat PO dose. Thus, not only was the PO medication equally efficacious, it also was well-tolerated by the pediatric population.
It should be noted, however, that this study focused only on those children with moderate croup, and that the large majority of ED patients diagnosed with croup (nearly 80%) did not participate in the study. In addition, future studies are needed to examine the optimal dosing of dexamethasone given recent work suggesting good benefit with lower dosages.
1. Johnson DW, et al. A comparison of nebulized budesonide, intramuscular dexamethasone, and placebo for moderately severe croup. N Engl J Med 1998;339: 498-503.
2. Klassen TP. Croup: A current perspective. Pediatr Clin North Am 1999;46:1167-1178.
3. Geelhoed GC, et al. Efficacy of a small single dose of oral dexamethasone for outpatient croup: A double blind placebo controlled clinical trial. BMJ 1996;313: 440-442.