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David W. Johnson, MD; Suzanne Schuh, MD; Gideon Koren, MD; David M. Jaffe, MD

Arch Pediatr Adolesc Med. 1996;150(4):349-355.

Abstract
Purpose
To determine if treating children who have acute, moderate croup with nebulized dexamethasone sodium phosphate in the emergency department results in clinical improvement by 4 hours and a decrease in the hospitalization rate.

Design
Randomized, double-blind, placebocontrolled trial.

Setting
Emergency department, children's hospital.

Patients
Fifty-five children with croup who were in moderate respiratory distress after treatment with mist for 30 minutes who met inclusion and exclusion criteria.

Measurements
Croup score, respiratory rate, heart rate, and oxygen saturation were assessed by one of us (D.W.J. or S.S.) before treatment and 2 and 4 hours after treatment. A staff pediatrician or senior pediatric resident, also "blind" to treatment, decided on admission to or discharge from the hospital. The differences between groups for change in croup score and hospitalization rate after treatment were analyzed.

Results
Evaluation of the croup scores disclosed a significant improvement in the dexamethasone-treated group compared with the placebo group at 4 hours (P=.005, Mann-Whitney U). However, the hospitalization rate was not statistically different at the end of treatment (33% vs 52%, P=.28) or after 24 hours (48% vs 60%, P=.56, Yates corrected ²). Our study has 80% power to detect a two-thirds reduction in hospitalization rate. Two patients with neutropenia treated with dexamethasone had a clinical course consistent with bacterial tracheitis.

Conclusions
Treatment of moderate croup with nebulized dexamethasone results in clinical improvement within 4 hours. We did not show a decrease in hospitalization rates, although our sample size was only large enough to detect a 67% reduction in the rate of hospitalization. Given the infectious complications and the absence of evidence for a sustained clinical effect, we do not recommend that patients with croup be treated with nebulized dexamethasone.

(Arch Pediatr Adolesc Med. 1996;150:349-355)

Author Affiliations
From the Divisions of Emergency Medicine (Drs Johnson and Schuh), and Clinical Pharmacology/Toxicology (Drs Johnson and Koren), Department of Paediatrics, The Hospital for Sick Children, University of Toronto (Ontario); and the Division of Emergency Medicine, Department of Pediatrics, Washington University School of Medicine, St Louis (Mo) Children's Hospital, (Dr Jaffe).

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