Source: Tyler A, Bryan MA, Zhou C, et al. Variation in dexamethasone dosing and use outcomes for inpatient croup. Hosp Pediatr. 2022;12(1):22-29; doi:10.1542/hpeds.2021-005854Investigators from multiple institutions conducted a retrospective study to evaluate the effects of a single dose or multiple doses of dexamethasone on outcomes in children hospitalized for croup. For the study, they reviewed data that had been collected for a prospective study conducted at 5 US children’s hospitals between 2014 and 2016. Participants for the current analysis were children 6 months to 6 years old hospitalized with croup. The Pediatric Health Information System database was reviewed and information on children in the study, including age, sex, level of medical complexity, insurance type, length of stay (LOS), charges, number of doses of dexamethasone, and 30-day reuse (repeat visits to the ED or re-hospitalization for croup with 30 days), abstracted. Medical record review was performed to characterize the severity of patients before first pharmacologic treatment using standardized criteria. Finally, the parents of study children provided data on race, ethnicity, and caregiver education level. Each child was characterized as receiving 1 or >1 dose of dexamethasone, including doses within 24 hours of initial presentation, in the ED and during the hospitalization. Study outcomes included LOS, hospital costs, and 30-day reuse. The association between single or multiple doses of dexamethasone with the outcomes were assessed using multivariate regression models. Models included child age, sex, race, ethnicity, medical complexity, severity, insurance type, caregiver education, and hospital size. LOS also was included in the model evaluating costs, and medical complexity and site were not included in the analysis of 30-day reuse.Data were analyzed on 234 children, including 145 (62%) who received 1 dose of dexamethasone and 89 (38%) who received >1 dose. Patient characteristics and severity were similar among those receiving 1 or multiple doses of dexamethasone. The rate of multiple doses ranged from 27.9% to 57.1% across the 5 hospital sites. In the multivariate model, LOS was significantly longer in children who received multiple doses of dexamethasone vs those receiving a single dose (43.7 and 27.0 hours, respectively; relative risk, 1.45; 95% CI, 1.30, 1.62). Costs were $4,157 for patients receiving multiple dexamethasone and $2,720 for those treated with a single dose. However, after adjusting for LOS and other confounders the difference was not statistically significant (adjusted difference, $-31.2; 95% CI, $-424, $362). Only 18 (7.7%) study children had a repeat ED visit or re-hospitalization for croup within 30 days, with no significant difference between those receiving multiple doses of dexamethasone and those treated with a single dose (OR, 0.87; 95% CI, 0.26, 2.95).The authors conclude that treatment with multiple doses of dexamethasone, compared to a single dose, was associated with longer LOS in children hospitalized with croup.Dr Winer has disclosed no financial relationship relevant to this commentary. This commentary does not contain a discussion of an unapproved/investigative use of a commercial product/device.The current investigators sought to utilize data gathered prospectively to measure the effects of single vs multiple dosing of dexamethasone for children with croup. As a long-acting corticosteroid, dexamethasone has a clinical half-life of 36-72 hours. It is recommended to give at least 1 dose of dexamethasone to all patients with a diagnosis of croup, regardless of setting or severity.1 Questions have arisen, however, over the dosing, route, and frequency of corticosteroid therapy in this disease.The authors of a Cochrane review found no evidence of difference in outcomes for oral vs intramuscular dexamethasone but concluded that systemic steroids were superior to inhaled.2 Additionally, the same systematic review showed faster recovery for patients who received 0.6 mg/kg dexamethasone compared to 0.15 mg/kg, but there were no identified differences in LOS or return visits between the dosages.The question of whether to re-dose dexamethasone when a child is continuing to have symptoms, such as stridor at rest, is a difficult one. In the current study, patients who received multiple doses of dexamethasone had approximately 17 hours longer LOS. This difference is likely some combination of the additional time between doses and longer post-steroid monitoring prior to discharge, largely related to the clinical course of the patients.However, another finding, specifically the wide range (27.9% to 57.1%) of patients receiving multiple doses between the participating hospitals, implies that there is likely a degree of unnecessary variation in practice and that standardization might lead to higher value care.There is variation in hospital-level rates of multiple-dosing of dexamethasone in children with croup. Patients who receive multiple doses of dexamethasone may have longer LOS than those who receive a single dose. (See AAP Grand Rounds. 2021;45[4]:39.)3Unmeasured in the current analysis are the potential side effects of corticosteroids, such as sleep disturbance and hyperactivity— all of which may be compounded by compound doses.4 Assessment of benefits versus harms of single versus multiple dexamethasone doses is the grist for a future randomized trial.