Letters

Steroids in the management of croup

EDITOR,--Iolo Doull's recommendations about the role of steroids in the management of croup are controversial and deserve comment.¹ An earlier publication that reviewed essentially the same reports was much more circumspect in its recommendations about nebulised steroids.²

There is now good evidence for a biological effect of oral, intravenous, and nebulised steroids in varying degrees of croup, but the evidence for a clinically important effect of nebulised steroids is less convincing. Studies relying on improvements in the croup score (which assigns numbers to clinical signs) as the main outcome measure^{3 4} can be criticised on the basis that the validity, reliability, and responsiveness of the score (in all its various forms) have not been evaluated. Hence, while these studies have shown a significant difference between groups given nebulised steroids and those given placebo, the extent to which these changes in the score reflect clinically important improvements in an individual child is unclear. Croup scores are rarely used in clinical practice.

Doull suggests that croup severe enough to warrant intervention could be treated at home with oral or nebulised steroids by general practitioners, and recommends that the child should be reviewed two to four hours later. This may be reasonable as an emergency measure while urgent admission to hospital is being arranged but in isolation could be dangerous.

Finally, Landau and Geelhoed remind us that 50-80% of children with croup who receive placebo in trials show considerable spontaneous improvement.² Any new management strategies, particularly for mild croup, need to be evaluated in the knowledge that most children recover without active treatment.

Consultant paediatrician Registrar in paediatrics Department of Child Health, Rotherham District General Hospital, Rotherham, South Yorkshire S60 2UD

P I Macfarlane, S Suri 

1. Doull I. Corticosteroids in the management of croup. BMJ 1995;311:1244. (11 November.) [Free Full Text]
2. Landau LI, Geelhoed GC. Aerosolized steroids for croup. N Engl J Med 1994;331:322-3. [Free Full Text]
3. Husby S, Agertoft L, Mortensen S, Pedersen S. Treatment of croup with nebulised steroid (budesonide): a double blind, placebo controlled study. Arch Dis Child 1993;68:352-5. [Abstract]
4. Klassen TP, Feldman ME, Watters LK, Sutcliffe T, Rowe PC. Nebulised budesonide for children with mild to moderate croup. N Engl J Med 1994;331:285-9. [Abstract/Free Full Text]