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Corticosteroids may be effective for most cases of croup, study shows

BMJ 2004; 329 doi: (Published 30 September 2004) Cite this as: BMJ 2004;329:762
  1. Barbara Kermode-Scott
  1. Calgary

    A large multicentre trial in Canada has found that that most, if not all, children with croup benefit from treatment with a corticosteroid.

    The authors of the randomised controlled trial say that a single dose of oral dexamethasone may be an effective treatment for mild croup. The benefits of dexamethasone for croup that is moderate to severe are already well established.

    Although the researchers found, as expected, that among untreated children with mild croup the burden of disease was low, the trial showed small but consistent and important benefits from treatment. Dexamethasone improved recuperation and helped children sleep better, according to the researchers (New England Journal of Medicine 2004;351:1306).

    Data were available for 354 children in the treatment group and 354 in the placebo group. Twenty six children (7.3%) in the treatment group and 54 (15.3%) in the placebo group returned to the hospital for care on account of croup within seven days of treatment (95% confidence interval for the difference 3.3% to 12.5%; number needed to treat to prevent one return visit: 13 (95% confidence interval 8 to 31)). The average number of hours of sleep lost because of croup was 2.9 (SD 3.8) in the treatment group and 4.2 (SD 4.7) in the control group (P<0.001).

    “Children with mild croup truly have a very self limited disease. It'll last on average only a couple of nights,” said the lead researcher, Dr David Johnson, an associate professor of paediatrics at the University of Calgary, Alberta. “From the medical perspective croup is a very mild disease. From a parent's perspective, and a child's perspective, croup is not mild. It's significant and it's frightening.”

    Symptoms of croup cause considerable anxiety in parents, stressed Dr Johnson. Parents may take their child to an emergency department for assessment and reassurance on more than one occasion during the same episode of the disease.

    Although the long term effects of dexamethasone treatment are not known, Dr Johnson and his colleagues in Canada's paediatric emergency research network advocate treatment for nearly all children with croup. Oral dexamethasone is a simple, inexpensive, and effective treatment, they say.

    “Our data support the use of dexamethasone in most—if not all—children with croup,” said Dr Terry Klassen, who chairs the department of paediatrics at the University of Alberta.

    In the trial 720 children with mild croup were enrolled at four Canadian paediatric sites: the Alberta Children's Hospital, Calgary, the Stollery Children's Health Centre in Edmonton, Alberta, the Winnipeg Children's Hospital in Winnipeg, Manitoba, and the Children's Hospital of Eastern Ontario in Ottawa, Ontario.

    Children were eligible for the study if they had mild croup (defined as onset within the previous 72 hours of a barking, seal-like cough and a score of 2 or less out of 17 points on the Westley validated croup scoring system on an initial medical evaluation). The study randomised 361 children to receive placebo and 359 to receive one oral dose of dexamethasone (0.6 mg per kg of body weight).

    The results of this study were consistent with the results of a small Australian study that assessed medical care for croup (BMJ 1996; 313: 140-2).

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