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Steroid administration in children with croup: an update.

Three Part Question

In [children with croup], is [nebulised budesonide as effective as oral/IM dexamethasone] at [reducing symptoms as measured using a croup score].

Clinical Scenario

A 3 year old boy was admitted to A&E via ambulance following a few hours history of being unwell with a barking ‘croupy’ cough, inspiratory stridor and a brief history of cyanosis. Due to the short history, alternative diagnoses such as epiglottitis could not be fully and safely excluded so nebulised budesonide was given instead of oral dexamethasone. The patient intially improved but the stridor returned rapidly after the nebuliser was stopped. The patient required nebulised adrenaline and a brief inpatient stay.

Search Strategy

Ovid Medline 1950-2008
Search terms: “croup” AND “budesonide” AND “dexamethasone”
Limited to English language papers

Search Outcome

21 papers found of which 15 were irrelevant or of insufficient quality. The remaining 6 papers are shown in the table below.

Relevant Paper(s)

Author, date and country Patient group Study type (level of evidence) Outcomes Key results Study Weaknesses
Geelhoed et al
80 children aged 5-158 months hospitalised with croup Groups: oral dexamethasone, nebulised budesonide, placebo 3-way randomised double-blind placebo controlled trialTime to achieve a croup score ≤1Dexamethasone 2 hours, budesonide 3 hours, placebo 8 hours (no significant difference between steroid groups)
Klassen et al
50 children aged 3 months-5 years with a croup score ≥ 3 after 15 minutes mist therapy Groups: Nebulised budesonide, nebulised placebo Randomised double-blind placebo controlled trialChange of 2 points in croup score 4 hours post-treatmentBudesonide 84%, placebo 56%All patients received oral dexamethasone in addition to their nebuliser
Klassen et al
197 children aged 3 months-5 years with a croup score ≥2 after 15 minutes mist therapy. Groups: oral dexamethasone + nebulised placebo, oral placebo + nebulised budesonide, oral dexamethasone + nebulised budesonide Randomised controlled trialMean change in Westley croup scoreBudesonide -2.3, dexamethasone -2.4, both -2.4.
Johnson et al
144 patients aged 24 ± 18 months with a croup score of 3-6 after 30 mins humidified oxygen Groups: nebulised budesonide, IM dexamethasone, placebo Randomised double blind placebo controlled trialChange in (Westley) croup scoreChange in croup score was significantly greater with IM dexamethasone than nebulised budesonide.All patients treated simultaneously with nebulised adrenaline.
Cetinkaya et al
60 patients aged 6 - 36 months diagnosed with croup Groups: nebulised budesonide, oral dexamethasone, IM dexamethasone, placebo Randomised controlled trialWestley croup score measured at 0, 24, 48 and 72 hoursNo significant difference between steroid administration methods.
72 children aged 3 - 126 months hospitalised with croup Groups: nebulised budesonide, nebulised placebo Randomised controlled trialChange in croup scores from 0-12 hoursNo significant difference between the two groupsAll children received oral dexamethasone in addition to their nebuliser


No studies show that budesonide is superior to dexamethasone in the treatment of croup. 4 studies show that there is no difference between the methods of steroid administration. One study shows that dexamethasone is superior to budesonide. One study suggests that the combination of nebulised and oral/IM steroid is better than dexamethasone in isolation. Other arguments for using dexamethasone include the fact that children tolerate nebulisers poorly and this may reduce the concentration of budesonide inhaled. In addition, dexamethasone is cheaper than budesonide and should therefore be used first wherever possible.

Clinical Bottom Line

Children presenting to the emergency department with croup should be given oral or IM dexamethasone as a first line method of steroid administration. However, nebulised budesonide is a safe and effective alternative in children who are not distressed by wearing a facemask.


  1. Geelhoed GC, Macdonald WB. Oral and inhaled steroids in croup: a randomized, placebo-controlled trial. Pediatr Pulmonol 1995; 20(6):355-61
  2. Klassen TP, Watters LK, Feldman ME, Sutcliffe T, Rowe PC. The efficacy of nebulized budesonide in dexamethasone-treated outpatients with croup. Pediatrics 1996;97(4):463-6
  3. Klassen TP, Craig WR, Moher D, Osmond MH, Pasterkamp H, Sutcliffe T, et al. Nebulized budesonide and oral dexamethasone for treatment of croup: a randomized controlled trial. JAMA 1998;279(20):1629-32.
  4. Johnson DW, Jacobson S, Edney PC, Hadfield P, Mundy ME, Schuh S A comparison of nebulized budesonide, intramuscular dexamethasone, and placebo for moderately severe croup. N Engl J Med 1998;339(8):498-503.
  5. Cetinkaya F, Tufekci BS, Kutluk G. A comparison of nebulized budesonide, and intramuscular, and oral dexamethasone for treatment of croup. Int J Pediatr Otorhinolaryngol 2004;68(4):453-6.
  6. Geelhoed GC Budesonide offers no advantage when added to oral dexamethasone in the treatment of croup. Pediatr Emerg Care 2005;21(6):359-62