Since the 1970s, corticosteroid use for croup has been debated. A 1989 meta-analysis by Kairys 21 demonstrated benefit in the inpatient setting. More recently, results of a meta-analysis showed that treatment with glucocorticoids is effective in improving symptoms within six hours, for up to 12 hours, with significant improvement in croup scores, shorter hospital stays, and less use of epinephrine. 2 [Evidence level A: meta-analysis of randomized controlled trials (RCTs)] A Cochrane review of 24 studies involving more than 2,000 children concluded that treatment with corticosteroids reduces the Westley croup score at six hours. 22 [Evidence level A: meta-analysis of RCTs] However, most of the included studies took place in emergency departments or on the hospital floor after admission. While it seems clear that steroids provide benefit in the treatment of croup, more recent studies have tried to determine the optimal method of administration and the applicability of the treatment in the office setting.
The use of antibiotics and short-acting beta-2-agonist bronchodilators in children with typical croup are rarely indicated because of the low incidence of bacterial infection (<1:1000 cases of croup) as well as for physiological reasons. An otorhinolaryngology (ORL) consultation for airway evaluation is indicated when croup symptoms are persistently severe despite treatment. Outpatient referral to ORL is recommended for children with multiple croup episodes and for those who present outside the usual age group for typical croup ( Figure 1 ).