The effectiveness of glucocorticoids in treating croup: meta-analysis
BMJ 1999; 319 doi: https://doi.org/10.1136/bmj.319.7210.595 (Published 04 September 1999) Cite this as: BMJ 1999;319:595
All rapid responses
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,
Specialist Registrar, Paediatrics,
Peterborough Dist
Hospital.
Beattie R.M.,
Consultant Paediatrician,
Peterborough Dist.Hosp.
Thorpe Rd.
Peterborough PE3 6DA.
[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.
Competing interests: No competing interests
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
specialist registrar in paediatrics
Department of Paediatrics, Addenbrooke's NHS Trust, Hills Road, Cambridge
CB2 2QQ
James D M Gould
consultant paediatrician
Department Child Health, Ipswich Hospital NHS Trust, Heath Road, Ipswich
IP4 5PD
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
Competing interests: No competing interests
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
Competing interests: No competing interests
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
Sally Hanna.
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.
Competing interests: No competing interests
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.
Competing interests: No competing interests
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.
Competing interests: No competing interests
MANAGEMENT OF CROUP, CONTROVERSIES STILL EXIST.
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,
Specialist Registrar, Paediatrics,
Peterborough Dist
Hospital.
Beattie R.M.,
Consultant Paediatrician,
Peterborough Dist.Hosp.
Thorpe Rd. Peterborough PE3 6DA.
[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.
Competing interests: No competing interests