Dexamethasone in Croup

1. See Also
   1. Croup
   2. Dexamethasone
2. Indications
   1. Moderate Croup with 2-3 awakenings on prior night
   2. Strongly consider even in mild croup
3. Contraindications
   1. Exposure to Varicella Zoster within prior 3 weeks
   2. Varicella Virus Vaccine (Varivax) in prior 2 weeks
   3. Pre-existing Immunodeficiency
4. Preparations
   1. Dexamethasone
      1. Oral as effective as intramuscular
      2. Dose
         1. Moderate to severe croup: 0.6 mg/kg IM/IV/PO
         2. Mild croup: Consider 0.15 mg/kg PO
            1. However 0.6 mg dose is most effective
         3. Maximum dosage in children: 10 mg
      3. Preparations
         1. Oral suspension only available as 0.5 mg/5 ml
            1. Requires considerable volume for dose
         2. Injection solution (Decadron 4 mg/ml)
            1. Use instead of suspension for high concentration
            2. Mix with Ibuprofen suspension or chocolate syrup (or have pharmacist compound)
         3. Oral tablets available at up to 4 mg
            1. Consider crushing tablets into chocolate syrup
   2. Nebulized Budesonide (Pulmicort)
      1. Pulmicort Nebule Dose
         1. Age <8 years old: 2.5 mg/day divided twice daily (full 2.5 mg dose given in ED)
         2. Age >8 years old: 5 mg/day divided twice daily (full 5 mg dose given in ED)
      2. Indications: May have role in mild croup exacerbations
         1. Consider for child who is Vomiting the Dexamethasone
      3. Dexamethasone is preferred
         1. Appears comparable to low dose Dexamethasone (0.15)
         2. Not as effective as high dose Dexamethasone (0.6 mg)
         3. Much more expensive than Dexamethasone
5. Efficacy in Croup
   1. Clinical improvement
      1. Improvement onset in 6 hours
      2. Improvement continues at least 12-24 hours and may last 60-72 hours
   2. Decreases need for intubation by 80%
6. Adverse Effects
   1. Increased appetite
   2. Increased aggressiveness
7. References
   1. Rittichier (2000) Pediatrics 106:1344-8
   2. Wright (2002) Emerg Med Clin North Am 20(1):93-114