Original Article
Comparison of the Effect of Cold Drink and Dexamethasone, and
their Combined Effect on Children with Croup
Authors
Mojgan Faraji-Goodarzi1, Nadereh Taee1, Mehrnoosh Mohammadi-Kamalvand2
Affiliations
1 Faculty of Medicine, Department of Pediatrics, Lorestan
University of Medical Sciences, Khorramabad, Iran.
2 Student Committee research, Lorestan University of
Medical Sciences, Khorramabad, Iran
Key words
cold drink, dexamethasone, croup
Bibliography
DOI https://doi.org/10.1055/s-0043-118537
Published online: 2017
Drug Res
© Georg Thieme Verlag KG Stuttgart · New York
ISSN 2194-9379
Correspondence
Nadereh Taee
Faculty of Medicine, Department of Pediatrics
Lorestan University of Medical Sciences
Khoramabad
Iran
Tel.:  + 98/91/23546 153,
+ 98/663/3120 172, + 98/912/5524 355
dr.n.taee@gmail.com
Introduction
Croup is a clinical syndrome which include inspiratory stridor,
coughing with a dog-like sound, noise obstruction and respiratory
distress symptoms. This disorder is a common disease in young ba-
bies and children [1]. Croup is divided into two categories: acute
and chronic viral laryngotracheobronchitis and spasmodic croup
[2]. The severity of croup ranges from mild, to moderate and se-
vere, of which moderate and severe cases required hospitalization
[3, 4]. In mild croup, symptoms such as hoarseness, croup cough,
mild fever, loss of appetite, can be treated within few days. In se-
vere croup rapid breathing, inspiratory stridor, pulling the chest
Faraji-Goodarzi M et al. Effect of Cold Drink and Dexamethasone …  Drug Res
Thieme
Abs tr ac t
Aims  Croup is a clinical syndrome which included inspiratory
stridor, coughing with a dog-like sound, noise obstruction and
respiratory distress symptoms. This present study was con-
ducted to compare the effects of cold drink and dexametha-
sone, and the effects of their co-administration on children’s
croup.
Materials and Methods  In this study, all patients with croup
admitted to the emergency ward of Madani Hospital Khor-
ramabad were divided through the simple randomized method
into 3 groups after informed consents were taken from their
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parents. The first group was given cold drink, second group
with dexamethasone (DM), and the third group were given the
combined treatment simultaneously. The patients in the first
and second groups who did not show signs of improvement
received the simultaneous treatment similar to the third group.
The data were analyzed using the SPSS software through de-
scriptive statistics and inferential statistics including multi-field
variance analysis and co-variance analysis.
Result  The results of the study indicated a statistically signifi-
cant between the 3 group in terms of improvement time-scale
of croup clinical symptoms (P = 0.001). There was no significant
difference observed between the effects of other variables on
improvement time-scale of croup clinical symptoms.
Conclusion  The cold drink has less treating effect than DM
and combined simultaneous treatment method. Also, DM had
more influence than simultaneous treatment method. In addi-
tion, other variables including age, sex, birth weight, BMI, res-
piratory allergy and previous croup history did not influenced
improvement time-scale and only type of intervention influ-
enced improvement time-scale of croup clinical symptoms.
when you inhale, air thirst, and cyanosis caused by the lips and nails,
if these obstructions are not treated, the patient passes out. Oc-
currence of acute respiratory infection with multi factor is impor-
tant for communication such as age, season of the year, the clinical
syndrome, an area of contact and infectious agent.
Croup disease is caused by several kinds of viruses which varies
from parainfluenza types 1, 2 and 3 viruses, Influenza A, and B, res-
piratory syncytial virus, adenovirus, rhinovirus, enteroviruses and
so on. For example 75 % of croup is caused by parainfluenza virus
type 1 [5–7]. The prevalence of croup is 8.9 % in society and the
peak incidence is between 7 and 36 months of age. The incidence
 Original Article
▶Table 1   Demography of the patients studied.
Demography parameter Values
Number of patients 75
Number of male 50
Number of female 25
Minimum age of patient 3months–6years
The minimum birth weight of patients 2700 g
The maximum birth weight of patients 4000 g
Minimum BMI 11.8
Maximum BMI 22.5
Positive respiratory allergies 24 %
Positive previous croup record 34.6 %
in boys to girls is 5/1. In a study of 14-year-old patient hospitalized
for croup in Canada between 1988 and 2000, increased prevalence
in mid-autumn twice every two years, and an increase in summer
was observed every year [8, 9].
Also, for every 1,000 children in the United States, less than 2 %
of the children required hospitalization, 5–5.1 % needed spinal in-
tubation, but deaths from croup is rare [10]. Indications for hospi-
talization include: epiglottitis and actual or suspected cases of ep-
iglottitis, progressive stridor, cyanosis, pallor, respiratory distress,
hypoxia, restlessness, loss of consciousness, and high fever toxic
children.
Intramuscular or oral DM will reduce croup symptom for chil-
dren with mild or moderate or severe croup symptoms and reduc-
es the need for hospitalization. As a replacement therapy, pred-
nisone can be administered orally in 2 or 3 days and if there is a sig-
nificant airway obstruction, racemic epinephrine or L-epinephrine
is prescribed. This present study was conducted to compare the
effects of cold drink and dexamethasone, and their combined ef-
fects on croup in children referred to Madani Hospital emergency
ward.
Method
The study population
All patients with croup, both girls and boys aged 3 months to 6
years, were referred to Madani Hospital emergency ward in 2014
and after a full consent to participate in the study.
Sampling and sample size
The sample size for the survey is consistent with community, in
other words, patients referred to Madani Hospital emergency ward
in 2014 were selected. Considering using electrocardiograms with
standardization between 5.1 and 8.0. For each group, 24 subjects
were considered, bringing to the total sample of 72. But for cau-
tion purpose 3 others patients were added to bring the total sam-
ple size to 75.
In this study, all patients with croup were referred to Madani
Hospital emergency ward, a written informed consent was ob-
tained and they are categorized using Westley criteria into three
categories of mild, moderate and severe groups. Patients were di-
vided through the simple randomized method into 3 groups. The
Thieme
first group was given cold drink, second group with dexametha-
sone, and the third group were given a combined treatment of both
simultaneously. Cold drink contains (10 ml of distilled water plus
50 ml of cherry flavoured syrup), and a single oral dose of the dex-
amethasone suspension contains (50 ml of cherry flavoured syrup,
12.5 ml DM phosphate injection on 0.6 mg/kg of body weight (max-
imum 20 mg)).
Yet, about 9 scoring method for croup has stated and 3 of them
were valid. Westley standards is also one of the three methods [11].
This scoring method consists of 5 items including stridor, pulling
the chest air, cyanosis and level of consciousness that was rated in
the following table. However, if after 1 h in each of the first two
group, a signs of improvement were not observed such as a chill-
ing effect, the third group received an additional dexamethasone.
In this study, after grouping, the demography data studied includ-
ed birth weight, age, sex, clinical improvement Westley croup
standards, BMI, previous history of respiratory allergies, croup were
recorded and analyzed using statistical methods.
Sample criteria
Inclusion criteria
inclusion criteria in this study included children from 3 months to
Downloaded by: Cornell. Copyrighted material.
6 years old, those with moderate croup admitted to Madani Hos-
pital emergency ward.
Exclusion criteria
Exclusion criteria included mild to severe croup, congenital heart
disease contraindications corticosteroids, lack of parental consent.
Results
The total number of patients was studied was 75, of this number,
50 patients (66.7 %) were male, and 25 patients (33.3 %) were fe-
male. The minimum age of the patients are 3 months to 6 years.
The minimum birth weight of patients was 2700 g and maximum
was 4000 g. Minimum BMI of 11.8 and a maximum of 22.5 was con-
sidered. Respiratory allergies were positive in 24 % of patients. Pre-
vious croup record of 34.6 % was positive. Eligible patients in this
study were divided in 3 groups: the first group was given cold drink,
second group with DM, and the third group were given the com-
bined treatment simultaneously as shown in ▶Table 1.
32 % accounted for a history of positive respiratory allergies in
DM groups, 28 % in cold drink group, and the third group given the
combined treatment simultaneously accounted for 12 %. There was
no significant differences observed between the first two groups
in terms of respiratory allergy (P = 0.215). 32 % accounted for his-
tory of croup in DM groups, 52 % in cold drink group, and the third
group given the combined treatment simultaneously represents
20 %. There was a significant differences observed between the
groups (P = 0.056) as shown in ▶Table 2.
Sex in groups was shown in this study, there was no significant
difference between groups regarding gender (P = 0.383). As shown
in ▶Table 2 the average healing time was less in cold drink group
than the other two groups; dexamethasone and combined group.
For further evaluation of the test track (Tukey) was used. Track-
ing test group (Tukey) showed that the treatment effect of the cold
drink is significantly higher than the other two groups. The thera-
Faraji-Goodarzi M et al. Effect of Cold Drink and Dexamethasone …  Drug Res
peutic effect of combined treatment was more than the DM groups. ▶Table 2   History of patients in the 3 groups.
Age groups studied show a significant difference between the
History/Groups Dexamethasone Cold Combined
groups (P = 0.408) (▶Table 3).
Drink
Birth weight in groups shows that there was no significant dif-
History of 32 28 12
ference between the groups in terms of birth weight (P = 0.192). respiratory allergies
Height in groups shows that there was no significant difference be- History of croup 32 52 20
tween the groups in terms of height (P = 0.079). Current weight in
groups show that there was no significant difference between the
▶Table 3   Westley Criteria.
groups in terms of current weight (P = 0.181). BMI in the study
groups show that there was no significant difference between Clinical signs Degree Score
groups in terms of BMI (P = 0.436). Stridor Does not have 0
The results of covariance analysis on the effects of improving Resting with hearing 1
the duration only effect of the intervention (treatment) with im- Resting without hearing 2
pressive recovery, and other variables were not affected (▶ Fig. 1). pulling the chest Does not have 0
Slight 1
Average 2
Discussion and Conclusion Severe 3
The results showed that the effect of cold drink and DM treatment Entrance of air Normal 0
are synergistic. Minimal recovery time with DM was 30 min, 15 min
Decrease found 1
for cold drink treatment, and 30 min for the combined treatment,
Strongly decrease found 2
and a maximum recovery time of 180 min, 120 min and 300 min
Cyanosis Does not have 0
for DM, cold drink and combined treatment respectively. In the pre-

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With agitation 4
sent study, treatment with combined therapy is more effective than
During resting 5
DM alone. Also, DM was also more effective than combination ther-
Level Consciousness Normal 0
apy which is consistent with other studies.
But between gender and duration of treatment in the groups Changed 5

there was no statistically significant difference (P = 0.383). In a Mild croup:  < 4

study conducted on the relationship between variables such as age, Medium croup: 4–6
sex, birth weight, BMI, history of respiratory allergy and history of
Acute croup:  > 6
croup treatment investigated, positive respiratory allergies in the
DM group was 32 %, 28 % accounts for cold drink and 12 % accounts
for combined group. However, there was no significant difference
between allergies and duration of improvement observed in the
different groups (P = 0.215).
Positive croup previous experience in the DM group was 32 %,
52 % accounts for cold drink and 20 % accounts for combined group.
The history of croup and long-term improvement in the relation-
ship between different groups was not statistically significant
(P = 0.056).
The relationship between variables such as age (P = 0.408), birth
weight (P = 0.192), height (P = 0.215), current weight (P = 0.181)
and BMI (P = 0.436) and the duration of improvement was not sig-
nificant. The results about the relationship between treatment du-
ration was improved using statistical methods, and a one-way anal-
ysis of variance on the mean time to recovery in the 3 groups ▶Fig. 1 Recovery time in groups.
showed that, the type of treatment is associated with long-term
recovery. So that the mean duration of improvement in the com-
bined group as 44 %, was lower than the two other groups that inhaled corticosteroids are also effective in the treatment for
(P = 0.001). croup. Suleimani et al., in their study noted that the use of the drug
Soleimani et al., in a study to compare the effect of DM treat- does not affect the measured variables, but the oral method is more
ment of muscle by snapping on 68 children with croup, who were tolerable and efficient.
randomly divided into 2 groups, clinical symptoms, respiratory rate, In a similar study by Kristine et al., who compared the effects of
heart rate, saturation of oxygen and response to treatment was DM treatment of muscle by snapping over 277 children, aged 3
measured. It was concluded that intramuscular and oral dexameth- months to 12 years with croup, they were randomly divided into 2
asone had same effect, but because of the non-invasiveness, oral groups, treatment and follow-up by phone calls to parents. It was
route was used [12]. Most studies show the effectiveness of intra- observed that 51 % of patients recovered (75 patients for muscu-
muscular dexamethasone in croup, but recent studies have shown lar) and (66 patients for oral), 29 % re-visited for further assessment

Faraji-Goodarzi M et al. Effect of Cold Drink and Dexamethasone …  Drug Res

 Original Article
(45 patients for muscular) and (35 patients for oral) and 8 % for oth-
ers (11 patients for muscular) and (12 patients for oral). The need
for other therapies such as epinephrine and oral. In their study,
there was no significant difference between the effect of intramus-
cular and oral dexamethasone [13].
The use of DM is significantly associated with the duration of re-
mission and relapse in patients. Study in relation to the treatment
by Fitzgerald et al., compared the therapeutic effect of nebulized
epinephrine and nebulized adrenaline in the treatment of moder-
ately severe croup on 66 children with complications, length of hos-
pital stay, and improvement of clinical symptoms were found to be
significantly different between the 2 groups [14].
In the present study, the therapeutic effect of two different
methods, in the treatment of croup have been investigated, both
groups had identical demographic characteristics randomly divid-
ed into two groups. Results obtained by using analysis of variance
revealed that between variables such as complications, length of
stay, there was no significant difference in clinical improvement.
According to the data obtained in this study, we reached the
conclusion that the impact of cold drink, from dexamethasone and
the combined treatment is more variable during recovery, but other
does not. Since the effect of cold drink in improving the symptoms
of croup, compared with the dexamethasone was experimentally
more, and more parents want to use cold drink for rapid healing of
recurrent cold, therefore, we had less disease in affected children.
Cold drink has been used for centuries to improve symptoms of
croup. Hot drink due to complications such as skin burns are less
used, and since the cold drink is more effective in improving symp-
toms, they are most commonly used. Cold drink due to the secre-
tions moisten the airways and soothe inflammation and relieve in-
flamed tract, reducing anxiety in children as an effective treatment
for croup.
Studies regarding the effects of hot drink was performed in im-
proving signs and symptoms of croup, but a low number of samples
discouraged a conclusive results. The cold drink has less treating ef-
fect than DM and combined simultaneous treatment method.
Ethical approval
All procedures performed in studies involving human participants
were in accordance with the ethical standards of the institutional
and/or national research committee and with the 1964 Helsinki Dec-
laration and its later amendments or comparable ethical standards.
Acknowledgments
We greatly thank the “Lorestan University of Medical Sciences, kho-
ramabad, Iran”.
Thieme
Conflict of Interest
The authors deny any conflict of interest in any terms or by any means
during the study. All the fees provided by research center fund and
deployed accordingly.
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Faraji-Goodarzi M et al. Effect of Cold Drink and Dexamethasone …  Drug Res