Background: Croup is a common cause of respiratory distress in young children secondary to viral infection. Oral dexamethasone has been shown to improve the symptoms of respiratory distress caused by croup. The frequency of repeat dexamethasone dosing during admission or on discharge is not well understood, and the effect of re-dosing on re-admission or recurrence of croup has not been well-established.
Methods: This is a retrospective cohort study of children ages 6 months to 7 years hospitalized with croup from 1/2013-1/2021. Exclusion criteria were direct admission to critical care, bacterial tracheitis, complex airway history (tracheostomy, operative laryngomalacia, chronic oxygen dependence), foreign body, congenital airway anomaly, vocal cord dysfunction, and treatment for asthma exacerbation. The main variable of interest was number of dexamethasone doses during admission or extra dosing on discharge (“for the road”). Resource utilization including specialist consultation and diagnostic imaging was also investigated. The primary outcome was re-admission or recurrence of croup symptoms following discharge. Associations between demographic and clinical variables and these outcomes were evaluated by the Fisher’s exact test or Chi-square test. Data are reported as frequencies (proportions) or median (interquartile range). The Generalized Estimating Equations models with a compound symmetry covariance matrix were utilized to explore the mentioned associations.
Results: A total of 485 children met inclusion criteria with 506 encounters. The median age was 17 (11, 25) months and the median LOS was 22 (16, 31) hours. During admission, 17% of children received no further dexamethasone, 66% received one dose, 9% received two doses, and 9% received three or more doses. 36% were prescribed dexamethasone at discharge (“for the road” dosing). 39% had diagnostic imaging performed, all of which included an x-ray. The readmission rate was 4% and recurrence without readmission was 8%. There was no significant difference in readmission or recurrence without admission for children who received “for the road” dexamethasone doses (p=0.23 and 0.99, respectively). The number of racemic epinephrine doses given during admission did not predict prescription of “for the road” dexamethasone (p=0.64).
Conclusions: Patterns in dexamethasone dosing were examined over an eight-year period. More than one-third of children were prescribed at least one “for the road” dose of dexamethasone which was not associated with a lower croup recurrence or readmission risk, suggesting this is not a useful intervention. The rate of imaging was unexpectedly high, with 39% of children receiving at least an x-ray on admission. Our study shows that there is likely an opportunity to decrease unnecessary interventions in children with croup, including “for the road” doses of dexamethasone and imaging.
