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Background Pediatric patients with croup are frequently admitted if they require two doses of racemic epinephrine(RE)in the emergency department(ED).We aimed to identify factors associated with the need for additional therapy(＞ 2 RE doses)among pediatric patients with croup.Methods We performed a single-center retrospective study of consecutive patients admitted from the ED with a diagnosis of croup between January 1,2011 and December 31,2015.Primary outcome was need for ＞ 2 doses of RE.Secondary out-comes included time to third RE and 72-hour ret visits.We performed logistic regression to identify factors associated with use of ＞ 2 RE doses during hospitalization,and survival analysis to identify time to dosing of 3rd RE from 2nd RE.Results Of 353 included admissions [250(70.8％)males,median age 1.48,interquartile range 0.97-2.51 years],106/353(30.0％)required ＞ 2 RE.In univariate logistic regression,only recent use of steroids within 1 day prior to presentation(4.18,1.48-11.83; P=0.007)was associated with need for＞2 RE.Survival from third RE was 0.74(95％CI 0.69-0.78),which was similar to the survival at 12 hours(0.70,95％CI 0.65-0.75).Ret visits occurred in 19(5.4％)patients,of whom 12/19(63.2％)were given RE.Conclusions Patients hospitalized for croup with recent use of steroids prior to ED presentation have a greater need for ＞ 2 RE during hospitalization.The majority who require inpatient RE will do so within 8-12 hours.These data provide informa-tion for risk stratification and duration of monitoring for patients hospitalized with croup.