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Rapid Responses: Rapid Responses published:
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Availability of suitable formulations of oral glucocorticoids for croup.
- Christopher Cates (4 September 1999)
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Treatment of Croup
- Andreas F Temmel, Christian Quint, Josef Toth (7 September 1999)
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Effectiveness of glucocorticoids for croup
- Juliet Irving (10 September 1999)
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Acknowledgement of the Cochrane Collaboration
- Terry P Klassen (16 September 1999)
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The effectiveness of glucocorticosteroids in treating croup
- Angela J Tillett (6 October 1999)
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MANAGEMENT OF CROUP, CONTROVERSIES STILL EXIST.
- S Acharyya (17 December 1999)
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MANAGEMENT OF CROUP, CONTROVERSIES STILL EXIST.
- S Acharyya (23 December 1999)
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Christopher Cates, General Practitioner Manor View Practice, Bushey Health Centre, London Road, Bushey WD2 2NN
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EDITOR, This review suggests that glucocorticoids improve the course of croup in children who are seen in emergency departments or admitted to hospital. Many children with croup are not referred to hospital, so how are primary care physicians to respond? I see no reason to suppose that children with croup should NOT benefit from steroids just because they are in the community, but unfortunately dexamethasone is only available in tablet form in the community in the UK. This is not a suitable formulation for small children. Nebulised Budesonide is available but is expensive and inconvenient, and the respules also go out of date alarmingly fast. As a result in our practice we have adopted the policy of using soluble Betamethasone tablets (Betnesol) which are equipotent to Dexamethasone and can be dissolved in a drink. They also have the advantage of tasting more palatable than soluble Prednisolone tablets (personal observation). The paper which prompted our change in practice was published in the BMJ in 1996 (1). We followed the example in that trial and have used a single oral dose of 0.15mg/kg (prescribed as 500mcg Betnesol tablets to dissolve in a drink) for children in the community with croup over the past 2 years. Others who decide that they wish to use oral steroids for children with croup in the community may find this information on available formulations useful, whilst we all wait for a much needed randomised controlled trial of glucocorticoids in croup in primary care. 1. Geelhoed G, Turner J, Macdonald W. Efficacy of a small single dose of oral dexamethasone for outpatient croup: a double blind placebo controlled clinical trial. BMJ 1996;313:140-2 I have no financial interest in any of the above products which might be used in the treatment of croup. |
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Andreas F Temmel, Senior Registrar Dept of ENT, University of Vienna, Christian Quint, Josef Toth
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Dear Editor, Croup or acute laryngotracheobronchitis is an acute viral inflammation of the upper and lower respiratory tracts, characterized by inspiratory stridor, subglottic swelling, and respiratory distress that is most pronounced on inspiration. It primarily affects children aged 6 mo to 3 yr, although it occasionally occurs earlier or later. The infection produces inflammation of the larynx, trachea, bronchi, bronchioles, and lung parenchyma. However, obstruction, caused by swelling and inflammatory exudate, is most pronounced in the subglottic region. Obstruction increases the work of breathing and, as the child tires, results in hypercapnia. A barking, often spasmodic, cough and hoarseness may mark the acute onset of inspiratory stridor, commonly at night. The child may awaken at night with respiratory distress, tachypnea, and supraclavicular, suprasternal, substernal, and intercostal inspiratory retractions. The mildly ill child may be cared for at home with supportive measures. The child should be made comfortable and kept well hydrated. Rest is important, because fatigue and crying can aggravate the condition. Humidification devices may ameliorate upper airway drying. We have very good resposes to glococorticoids which we usually prescribe as rectal suppository for outpatient therapy (any pharmacist can mix prednisolone tables in a suppository mass). With increasing or persistent respiratory distress, tachycardia, fatigue and cyanosis, the need for hospitalization is given. |
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Juliet Irving
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EDITOR, We have recently completed a paediatric research elective in Geelong Hospital, Australia. The purpose of this placement was to audit the management of childhood croup. We were therefore interested to read the paper published on September 4th 1999 by Ausejo et al(1). This paper, along with those that we analysed during our elective found only limited reference to the use of prednisolone. However, our audit revealed that 74% of those children with croup presenting to Geelong Accident and Emergency department received a dose of prednisolone as part of their therapeutic management. Additionally, our audit found that 38% of children were given a single dose of prednisolone to take home, to be used only as necessary, after receiving advice detailing suitable clinical indications for this. We were unable to find any published literature evaluating this practice but it appears to be routine procedure in Geelong. As our literature search was more limited than that cited in the article, we were interested to know if Ausejo et al came across data advocating this management. This appears to be a good idea as our audit found very low readmission rates to Geelong Hospital. However, as there is no quantitative data regarding this practice, perhaps this could be an area suitable for further research. Juliet Irving Final Year medical students, Birmingham University. Home Address: 10 Tiverton Road, Selly Oak, Birmingham B29 6BP. 1 Ausejo M, Saenz A, Ba P, Kellner J, Johnson D, Moher D, Klassen T. The effectiveness of glucocorticoids in treating croup: meta-analysis. BMJ 1999;319:595-600. |
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Terry P Klassen, Professor and Chair, Department of Pediatrics University of Alberta
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Dear Editor: It has been brought to my attention that we have omitted some key acknowlegements in our recently published systematic review of glucocorticoids for the treatment of croup. The protocol for this review was registered with the Acute Respiratory Infection (ARI) Review Group of the Cochrane Collaboration in 1997. Our review is currently under revision with the ARI Review Group and should be published shortly in one of the upcoming issues of the Cochrane Database of Systematic Reviews (CDSR). The ARI Review Group was very helpful in searching their database of trials identified through handsearching of relevant journals and providing insightful comments on our protocol. One advantage of having it published in the CDSR is that we will be able to update the review as new evidence is identified. The BMJ's policy of allowing for duplicate publication with the Cochrane Collaboration is an extremely important policy. It is my hope that other journals join in this support of the Cochrane Collaboration through like-minded policies. Terry Klassen |
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Angela J Tillett
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EDITOR The meta-analysis by Ausejo et al is certainly timely as the croup season approaches 1.Despite the usefullness of corticosteroids having been recognised for many years our experience is that children rarely receive this treatment in any form before admission to hospital. Geelhoed et al showed the benefit of a small single dose of dexamethasone for out-patient croup in 1996 2. and Godden et al confirmed the usefullness of nebulised budesonide 3 but there still appears to be a reluctance to treat mild croup despite the reduction in symptoms which untreated usually last 3-4 days. Our review of the casenotes of children admitted with croup between November 1996 and October 1997 identified 51 cases in a total paediatric population of 65 000. GP referrals accounted for 60% admissions [31/51] and none of these children had received either inhaled or systemic steroid apart from one child seen at a primary care casualty department who received hydrocortisone. Although formal croup scores were not recorded on admission, the majority of cases were mild and 90% [46/51] were discharged within 16 hours of admission i.e. the following morning if admitted at night, or the same day if admitted in the early hours.The duration of cough was greater than 8 hours in 55 % cases which suggests a window of opportunity for treatment if parents are encouraged to seek help. As discussed by Thomson2 in her commentary, dexamethasone is cheap, easier to administer and as effective as nebulised corticosteroids and perhaps should be added to the list of black bag essentials - albeit that the major determinant of treatment or indeed admission to hospital, may be the degree of parental anxiety generated by caring for a stridulous child in the middle of the night. Angela J Tillett James D M Gould 1. Ausejo M, Saenz A, Ba'Pham, Kellner J, Johnson D, Moher D and Klassen T The effectiveness of glucocorticosteroids in treating croup: meta-analysis BMJ 1999:319:595-600 2. Geelhoed G, Turner J and Macdonald W. Efficacy of a small single dose of oral dexamethasone for outpatient croup: a double blind placebo controlled trial BMJ 1996; 313:140-2 3. Godden C, Campbell M, Hussey M and Cogswell J . Double blind placebo controlled trial of nebulised budesonide for croup Arch Dis Child 1997;76: 155-158 |
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S Acharyya
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The recent meta-analysis[1] and the previous one[2] strongly support the use of glucocorticoids in croup. There are however considerable unresolved issues including which glucocorticoid, what route and for how long. We recently undertook a survey of 200 Paediatricians in 32 DGH (both consultants and trainees) and asked their views on the management of croup. The response rate was 75 percent. Only 50 percent of units had a written protocol. 126/152 used glucocorticoids for mild to moderate croup. Their preferred steroid was oral dexamethasone(70), nebulised budesonide(42) and oral prednisolone(14). 102/152 use a combination of oral and nebulised steroids. 26/152 do not routinely use any form of glucocorticoids for the management of croup. Of these 18 use nebulised adrenaline, 4 use mist therapy and 4 just reassure and observe. The views of consultants(92) and juniors(60) were equally diverse. 72/152 will admit a child with croup needing any form of treatment while 70/152 observe and send home if there is symptomatic improvement. Of these 70, 38 will observe for 6 hours while the rest think a 2 to 4 hours observation is sufficient. 10/152 were unsure. This study highlights several important issues. There is good evidence that glucocorticoids are helpful in the management of croup but the ideal preparation, route and duration of administration remain unresolved. This emphasises the need for further studies into the management of this common condition, in order that evidence-based consensus guidelines can be produced. Croup is typical of many other paediatric conditions in which there is an evidence base for management, but insufficient evidence to develop a clinical protocol by which, under clinical governance, the management in an individual unit can be judged. Acharyya S, Beattie R.M., [1] Monica Ausejo,Antonio Saenz,James D Kelnar,David W Johnson,David Moher, Terry P Klassen. "The Effectiveness Of Glucocorticoids in Treating Croup", Meta-analysis .BMJ 4th September 1999. [2] Kairy SW,Olmstead EM,OConner GT. "Steroid Treatment of Laryngotracheo-bronchitis, meta-analysis of the evidence from randomised trials", Paediatrics 1989, 83, p 683-93. |
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S Acharyya
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The recent meta-analysis[1] and the previous one[2] strongly support the use of glucocorticoids in croup. There are however considerable unresolved issues including which glucocorticoid, what route and for how long. We recently undertook a survey of 200 Paediatricians in 32 DGH (both consultants and trainees) and asked their views on the management of croup. The response rate was 75 percent. Only 50 percent of units had a written protocol. 126/152 used glucocorticoids for mild to moderate croup. Their preferred steroid was oral dexamethasone(70), nebulised budesonide(42) and oral prednisolone(14). 102/152 use a combination of oral and nebulised steroids. 26/152 do not routinely use any form of glucocorticoids for the management of croup. Of these 18 use nebulised adrenaline, 4 use mist therapy and 4 just reassure and observe. The views of consultants(92) and juniors(60) were equally diverse. 72/152 will admit a child with croup needing any form of treatment while 70/152 observe and send home if there is symptomatic improvement. Of these 70, 38 will observe for 6 hours while the rest think a 2 to 4 hours observation is sufficient. 10/152 were unsure. This study highlights several important issues. There is good evidence that glucocorticoids are helpful in the management of croup but the ideal preparation, route and duration of administration remain unresolved. This emphasises the need for further studies into the management of this common condition, in order that evidence-based consensus guidelines can be produced. Croup is typical of many other paediatric conditions in which there is an evidence base for management, but insufficient evidence to develop a clinical protocol by which, under clinical governance, the management in an individual unit can be judged. Acharyya S, Beattie R.M., [1] Monica Ausejo,Antonio Saenz,James D Kelnar,David W Johnson,David Moher, Terry P Klassen. "The Effectiveness Of Glucocorticoids in Treating Croup", Meta-analysis .BMJ 4th September 1999. [2] Kairy SW,Olmstead EM,OConner GT. "Steroid Treatment of Laryngotracheo-bronchitis, meta-analysis of the evidence from randomised trials", Paediatrics 1989, 83, p 683-93. |
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