inhaled steroids in croup

Last edited 04/2019

In mild croup (seal-like barking cough - however no stridor or sternal/intercostal recession at rest/respiratory distress)

  • a sytematic review has suggested that a a single dose of oral dexamethasone (0.15 mg/kg) to be taken immediately is of benefit in mild croup (1) compared with placebo.

Evidence base (1,2):

  • mild croup (1)
    • single oral dose of dexamethasone improves symptoms in children with mild croup, compared with placebo
    • humidification is often used in children with mild to moderate croup, but no RCT evidence to support its use in clinical practice
  • moderate to severe croup (1)
    • intramuscular or oral dexamethasone, nebulised adrenaline (epinephrine), and nebulised budesonide reduce symptoms compared with placebo
    • oral dexamethasone is as effective as nebulised budesonide at reducing symptoms
      • a dexamethasone dose of 0.15 mg/kg may be as effective as a dose of 0.6 mg/kg
      • addition of nebulised budesonide to oral dexamethasone does not seem to improve efficacy compared with either drug alone
    • unknown if heliox (helium-oxygen mixture) or humidification are beneficial in children with moderate to severe croup

  • the Cochrane review noted (2):
    • glucocorticoids reduced symptoms of croup at two hours, shortened hospital stays, and reduced the rate of return visits to care
    • uncertainty remains with regard to the optimal type, dose, and mode of administration of glucocorticoids for reducing croup symptoms in children
      • no significant difference in length of stay in the hospital or emergency department between children treated with dexamethasone compared to budesonide, or with dexamethasone compared to prednisolone
      • compared to those treated with betamethasone, children treated with dexamethasone were at a significantly increased risk for needing epinephrine
      • no significant difference between children treated with dexamethasone and those treated with prednisolone in the need for epinephrine or supplemental glucocorticoids
      • with respect to use of steroids in mild croup the review noted that
        • three studies included children with mild croup (Bjornson 2004; Geelhoed 1996; Luria 2001). Sample sizes tended to be small with a median of 72 (interquartile range (IQR) 54 to 99) children
          • Bjornson et al noted that for children with mild croup, dexamethasone is an effective treatment that results in consistent and small but important clinical and economic benefits (3)


  1. Johnson DW. Croup. BMJ Clin Evid. 2014; 2014: 0321
  2. Gates A et al. Glucocorticoids for croup in children.Cochrane Database Syst Rev. 2018 Aug 22;8:CD001955
  3. Bjornson CL et al. A randomized trial of a single dose of oral dexamethasone for mild croup. N Eng J Med 2004; 351:1306-13.