What are the indications for cortisone (corticosteroids) in pediatric croup?

Indications for Corticosteroids in Croup

Corticosteroids should be administered to all children with croup of any severity who present for medical care, as they reduce symptoms, hospitalizations, and return visits regardless of initial disease severity. 1

Primary Indications

Moderate to Severe Croup

• Corticosteroids are the standard of care for moderate to severe croup, reducing hospitalizations, length of illness, and need for subsequent treatments compared to placebo. 2
• Children with moderate to severe croup presenting to emergency departments should receive corticosteroids, as they reduce hospital admissions, intensive care unit admissions, and need for endotracheal intubation. 3
• Glucocorticoids reduce croup scores significantly at 2 hours (SMD -0.65), 6 hours (SMD -0.76), and 12 hours (SMD -1.03) compared to placebo. 1

Mild Croup

• Even children with mild croup who seek medical care should receive corticosteroids, particularly if risk factors for hospital admission exist. 3
• More liberal use of systemic corticosteroids in primary care settings has been associated with reduced hospital admission rates. 3
• Lower doses of dexamethasone (0.15-0.3 mg/kg) may be appropriate for mild disease. 2

Severe Croup Requiring Intubation

• In severe croup requiring intubation, oral prednisolone 1 mg/kg every 12 hours decreases the duration of intubation and need for reintubation. 4

Recommended Agents and Dosing

First-Line Treatment

• Oral dexamethasone 0.6 mg/kg (maximum 10-12 mg) is the preferred treatment due to ease of administration, availability, and low cost. 2
• Dexamethasone 0.15 mg/kg may have similar efficacy to 0.6 mg/kg, with high-certainty evidence showing no difference in return visits or readmissions between these doses (RR 0.91). 1

Alternative Routes

• Intramuscular dexamethasone 0.6 mg/kg is reserved for children who are vomiting or in severe respiratory distress unable to tolerate oral medication. 2, 5
• Nebulized budesonide 2 mg is effective and appears equivalent to oral dexamethasone, though oral corticosteroids are often preferred. 4, 2
• Oral dexamethasone and nebulized corticosteroids are equally effective in croup management. 6

Important Note on Route

• Corticosteroids from hand-held inhalers with spacer devices have NOT been shown to be effective in croup. 6

Timing and Onset of Action

• Dexamethasone has an onset of action of approximately 6 hours after administration. 5
• Racemic epinephrine may be administered concurrently for immediate symptom relief while awaiting corticosteroid effect. 5
• The correct dosage is critical—lower steroid dosages have proven ineffective in treating croup. 5

Safety Profile

• The risk of a single or short course of systemic corticosteroids is minimal, with the only potential significant adverse effect being increased risk of severe varicella infection. 4
• Corticosteroid-induced complications in croup are rare overall. 2
• Short courses of nebulized budesonide have no major adverse effects and likely cause fewer adverse effects than systemic corticosteroids. 4

Common Pitfalls to Avoid

• Do not withhold corticosteroids from children with mild croup—the benefits clearly outweigh risks even in self-limiting disease. 4, 2
• Do not use inadequate doses of dexamethasone (less than 0.15 mg/kg), as lower doses have proven ineffective. 5
• Do not rely solely on humidified air or racemic epinephrine without corticosteroids in children presenting for medical care. 5
• Remember that dexamethasone takes approximately 6 hours to work, so bridging therapy with racemic epinephrine may be needed in severe cases. 5