Yet as we’ve seen, the number of kids who die from croup is minuscule; and just a tiny fraction are deemed to be in any danger whatsoever. Kirsten Bechtel of the Yale University School of Medicine told me that she’d worked as a pediatric emergency physician for 24 years. In all that time, she said, she saw maybe 10 instances of croup—out of “thousands” in all—in which the child appeared to be in real trouble, with slowed respiration and signs of cyanosis. One of Johnson’s studies in Alberta found that about 85 percent of kids who show up with croup at general emergency departments turn out to have a “mild” form of the condition. Less than 1 percent have symptoms labeled as “severe.”
Thinking back on my own experience, it’s pretty clear my son had mild croup; my daughter’s case may have been classed as “moderate.” In any case, Johnson says his research finds that croup doesn’t tend to worsen over time: If your kids start off with mild symptoms, they’ll likely stay that way and clear up on their own.
Still, it’s often treated quite aggressively by doctors. A study published last year put some numbers to the problem. The authors pointed out that three kids with croup are admitted to the hospital for every one whose case might be “severe.” More than 27 percent of all croup patients receive a spritz of epinephrine, though this is only indicated for about 15 percent. Another one-fifth of children receive a chest x-ray, which tends to be of little value. One in eight are put on antibiotics, despite the fact that croup is almost always viral.
Johnson agreed that these are problems, especially the overuse of x-rays and antibiotics. But he wasn’t really worried by the fact that, according to this study, three-quarters of all kids who show up at the ER with croup are given dexamethasone. The treatment helps even those with mild symptoms, Johnson said. According to his research, a single dose can halve the odds of their return to the ER; it also seems to save parents from some stress and sleep loss.
But it seems to me that many of those kids and parents might have gotten a similar benefit from a simple conversation. I thought back to my interactions with the triage nurse at the ER. She’d seemed a little bored. What if she’d sent us home right there and then, maybe with some tips to calm us down? I’m sure that if she’d run us through the stats on croup—if she’d told us that it’s almost never truly dangerous, that it resolves itself and rarely worsens over time—the conversation would have eased our sleep in the absence of any medicine. More to the point, we could have skipped the foofaraw with the ER doctors. (If I hadn’t been so addled by the wheezing, and so afraid my child’s time was running out, I might have gotten this advice by phone. Our pediatrician’s office has a nurse on call to do just this.) So I asked Johnson: Is it possible that a talking-to would be effective, too—and keep ER visits to a minimum?
Johnson agreed this might be useful, but he noted it would take a large, randomized trial to be sure of the effect. In the meantime, though, there’s every reason to continue treating kids at the ER with dexamethasone. It spares them some discomfort, and the side effects are negligible. A single dose, he added, “costs pennies, even in the US.”
I’d seen the tab; he was (sort of) right. The dexamethasone my daughter got was billed at $2.86. But that was just the medicine. The hospital also charged us for its doctors’ time and judgment—their “medical decision making of moderate complexity,” to be specific—and did so at a rate of $4,572 on the first visit and $6,151 for the second. Even though my wife and I are privileged to have insurance, even though our kids were seen in-network, and even though their ailments were both banal and non-life-threatening, we still ended up more than $3,000 in the hole. When I told Johnson this, the Canadian was dumbfounded. “Holy mackerel,” he said. “Holy mackerel!”