Ask the Doctor: Steroids for Croup?

Michelle Asks:

I was wondering what you would suggest for treatment for croup. My son has had it twice this year and both times the doctor prescribed steroids. Is there any other treatment for croup? Thanks!

What is Croup?

Croup is classified as an Upper Respiratory Infection and is generally caused by a virus.  The symptoms of croup are classically runny nose and cough.  The cough is very characteristic and sounds “barky” or “seal-like.”  In most kids, these are the only symptoms they will have and we call it mild croup.

In rare situations croup can be more serious, in which case we call it moderate or severe croup.  The definitions of moderate and severe croup vary but most people would agree that moderate and severe croup are characterized by stridor.  Stridor is a high-pitched noise that your child makes when taking a breath.  Click on the video below to see a child with stridor.

What really gets us doctors concerned is what we call Stridor at Rest.  This means that your child is making this stridor noise even when they are NOT crying and upset.  It is common for children who are really upset and crying to make the stridor noise, but it should only last as long as the crying lasts and completely resolve when the crying resolves.  Kids who have stridor at rest need to be seen by their doctor or in the ER if your doctor is not available.

Why Does Croup Make it Hard to Breathe?

Croup tends to cause irritation in the back of the throat around the area of the vocal cords and down in the trachea (the tube that leads from your mouth to your lungs).  When the swelling in this area is mild, you get the “barky” cough.  If the swelling is more severe you get stridor and may have difficulty breathing.

What are the Treatments?

There are two different types of treatment: home-based treatments and medical treatments.

Home-based treatments

One classic home-based treatments is taking your child into the bathroom with the shower turned on.  The rationale is that the warm steam produced by the shower helps with the swelling in the throat.  However, when doctors have studied this by giving children in the ER warm humidified oxygen, it does not seem to make a huge difference.  Regardless, many parents swear by this technique and I often recommend it to my patients.

The other classic home-based treatment is taking your child outside into the cool air.  The rationale is that the cool air will reduce some of the swelling in the back of the throat.  Again many parents swear by this and I often recommend it to my patients, but there is no hard evidence to suggest that it works.

So if your child is making the stridor noise you can attempt these things at home.  If things are not better after a brief trial of the home-treatments, then a trip to the doctor or ER is in order.

Medical Treatments

There are really two medical treatments for croup – breathing treatments and steroids.

The breathing treatments (called racemic-epinephrine) are different from those that kids with asthma use.  The medicine in the racemic-epinephrine treatments reduces the swelling in the back of the throat and will almost always make the stridor go away.  The problem with the breathing treatments is that they are only temporary.  They last about 2-4 hours and then the swelling comes back.

So we also give steroids (usually Decadron) when we give the breathing treatments.  The steroids last 18-36 hours and in most cases will prevent the stridor from coming back.  There is no real benefit to giving the steroids in a shot, unless you just cannot get your child to take them by mouth.  In my experience, I almost never have to give the shot.

But What if my Kid just has Mild Croup (No Stridor)?

This is the real question.  Kids with stridor and trouble breathing are sick and need medication.  But what about the kids that just have the “barky” cough and no stridor?  Do they need steroids to prevent the stridor?

Well, a group of researchers asked this question and published their results in the very well-respected New England Journal of Medicine.  This is what they found…

Children with mild croup who were given steroids:

  1. Were less likely to return to the doctor. If you did not get the steroids there was about a 15% chance you would go and see your doctor again.  However, even if you did get the steroids there was still about a 7.5% chance you would go back to the doctor.
  2. Had quicker resolution of symptoms (barky cough). Kids that got the steroids had fewer symptoms in the first 24 hours.  However, almost all kids were better at 72 hours whether they got the steroids or not.
  3. Got more sleep. Kids given steroids got, on average, 1.3 hours more sleep at night probably on account of the fewer symptoms mentioned above.
  4. Had parents that were less stressed. When parents were asked about their stress and given a score based on their response, there was a tiny difference in stress levels that favored using steroids.

However, these are not what I would consider significant outcomes.  In this study, NONE of the kids who did not receive steroids got sick enough to be admitted to the hospital or had any other bad outcome.  In fact all kids got better whether they were given steroids or not – most after only three days.

So you might ask, why not just give the steroid?  To that question I say – steroids are potent immune-suppressing medications.  They actually make it harder for your body to fight infections.  They have a long list of very nasty side-effects.  It is true that they do reduce swelling, and in the case of severe croup with stridor, they are probably a very good idea.  However, I am not so sure that they are indicated in cases of mild croup just so that your child can get one extra hour of sleep.  Of course that is just my opinion.  For you and your family… You Decide.

References

NEJM article

Humidified Air article

Comments

  1. Thanks so much Jason!! Very helpful!!!

  2. Thanks, this really answered most of my concerns in one spot! I was wondering though if you could elaborate a bit on the side effects and how steroids suppress the immune system. My son was treated with steroids the last time he got croup and the doctor said they were perfectly safe. I would love to know otherwise so I can avoid it next time and tell her exactly why. Thanks!

  3. A single dose of steroids or a short 3-5 day course is safe. However, it is probably not necessary in many cases. Steroids do all kinds of things. Mild suppression of the immune system is just one of those things. While this is a minor effect I am not sure why we want to do this unless we have good reason to believe that it is really necessary (like severe croup).

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