What is the recommended treatment for croup using dexamethasone (DEXA)?

Treatment of Croup with Dexamethasone

Administer a single dose of dexamethasone 0.6 mg/kg (maximum 16 mg) orally, intramuscularly, or intravenously for all children with croup, regardless of severity. 1

Dosing and Administration

• Standard dose: 0.6 mg/kg with a maximum of 16 mg per dose 1
• Route selection: Oral administration is preferred when the child can tolerate it, as it is equally effective as intramuscular or intravenous routes and avoids injection pain 1, 2
• Bioavailability: Oral and intravenous dexamethasone have equivalent 1:1 bioavailability 3
• IV administration precaution: When using IV route, infuse slowly over several minutes to prevent perineal burning 3
• IM route: Reserve for children who are vomiting or in severe respiratory distress unable to tolerate oral medication 4

Clinical Efficacy and Timing

• Onset of action: Symptoms begin improving as early as 30 minutes after administration, with peak effects at 6-12 hours 1, 5
• Duration of action: Clinical effects last approximately 24-72 hours from a single dose 1
• No tapering required: The single-dose regimen does not cause significant adrenal suppression and does not require tapering 1
• Hospital stay reduction: Dexamethasone significantly shortens hospital stays and reduces need for subsequent treatments compared to placebo 5

Adjunctive Therapy for Moderate-to-Severe Croup

For children with significant respiratory distress (marked stridor at rest, severe retractions, or respiratory compromise):

• Nebulized epinephrine: Administer 0.5 mL/kg of 1:1000 solution (maximum 5 mL) by nebulizer 1, 6
• L-epinephrine substitution: If racemic epinephrine is unavailable, L-epinephrine (1:1000) at 0.5 mL/kg up to 5 mL is an acceptable alternative 6
• Timing consideration: Use nebulized epinephrine for immediate symptom relief while waiting for dexamethasone to take effect, as epinephrine provides rapid but short-term improvement (15-30 minutes) while dexamethasone provides longer-lasting relief 1, 3

Alternative Corticosteroid Options

• Nebulized budesonide: Equally effective as oral dexamethasone but less practical due to higher cost, longer administration time, and need for nebulization equipment 1, 3
• Avoid: Do not use nebulized corticosteroids from hand-held inhalers with spacers—they are ineffective for croup 1

Lower Dose Considerations

• Mild croup: Some evidence supports using lower doses (0.15-0.3 mg/kg) for mild, self-limiting disease 4, 7
• Comparative efficacy: A randomized trial demonstrated that 0.15 mg/kg was equally effective as 0.6 mg/kg for moderate-to-severe croup, with similar time to symptom resolution (approximately 8 hours) 7
• Current standard: Despite this evidence, the American Academy of Pediatrics continues to recommend 0.6 mg/kg as the standard dose for all severities 1

Safety Profile

• Adverse effects: Corticosteroid-induced complications in croup are rare 4
• Single-dose safety: No significant adverse reactions occur with single-dose dexamethasone treatment at either 0.15 mg/kg or 0.6 mg/kg 7
• Prolonged therapy caveat: Consider antifungal prophylaxis only if prolonged steroid therapy is required (not applicable to standard single-dose croup treatment) 3

Common Pitfalls to Avoid

• Underdosing: Do not reduce the dose below 0.6 mg/kg for moderate-to-severe croup without clear rationale 1
• Delaying treatment: Administer dexamethasone promptly upon diagnosis; earlier treatment correlates with better outcomes 5
• Wrong formulation: Avoid using inhaled corticosteroids (MDI with spacer) as they lack efficacy in croup 1
• Premature discharge after epinephrine: Observe children for at least 2-3 hours after nebulized epinephrine administration, as symptoms may recur when the short-acting effect wears off 8