Tools for Practice


#102 Coughing up the Data on Croup


CLINICAL QUESTION
Are glucocorticoids beneficial for mild to moderate croup and, if so, is lower dose equivalent to standard dose?


BOTTOM LINE
Glucocorticoids, including dexamethasone, are beneficial in the treatment of mild to moderate croup, with a NNT of 5 for symptom improvement and a NNT of 17 for return to care. Low-dose dexamethasone (0.15 mg/kg) may be equivalent to the more commonly prescribed 0.6 mg/kg. 



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EVIDENCE
A systematic review (38 trials, 4,299 patients) evaluating glucocorticoids (the majority used dexamethasone) for mild to moderate croup found:1 
  • Significant improvement in croup symptoms at six hours: Number Needed to Treat (NNT) 5 (95% Confidence Interval 3 to 11). 
    • Similar improvement at 12 and 24 hours. 
  • Fewer return visits to emergency and/or (re)admissions: NNT 17 (13 to 28). 
  • Shorter time spent in emergency or hospital: mean difference 12 hours (5 to 19 hours). 
  • No reported adverse events. 
The above review included two small randomized controlled trials (137 patients with mild to moderate croup) that compared 0.15 mg/kg to 0.6 mg/kg of dexamethasone. There was no difference in: 
  • Change in croup score from baseline at six hours, Standard Mean Difference -0.02 (-0.37 to 0.32). 
  • Return visits and/or (re)admissions, Risk Ratio 1.04 (0.62 to 1.75).  
Limitations: small sample size.  Context:   
  • Even children with mild croup (croup score <2) benefit from glucocorticoid treatment.2 
  • Symptom improvement of steroids may be evident in ten minutes, with statistically significant improvement at 30 minutes.3 
  • A retrospective observational study found reduced hospital and intensive care admission rates, length of stay and intubations when 0.6 mg/kg dexamethasone was introduced and used in the hospital protocol (19801995).4 These rates did not change when 0.6mg/kg was replaced by 0.15 mg/kg in 1995.5  


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Author(s):

  • Christina Korownyk MD CCFP
  • G. Michael Allan MD CCFP
  • Michael R Kolber BSc MD CCFP MSc
  • Ricky D. Turgeon BSc(Pharm) ACPR PharmD

1. Russell KF, Liang Y, O'Gorman K, et al. Cochrane Database Syst Rev. 2011; (1):CD001955.

2. Bjornson CL, Klassen TP, Williamson J, et al. N Engl J Med. 2004; 351(13):1306–13.

3. Dobrovoljac M, Geelhoed GC. Emerg Med Australas. 2012; 24(1):79–85.

4. Geelhoed GC. Ann Emerg Med. 1996; 28:621–6.

5. Dobrovoljac M, Geelhoed GC. Emerg Med Australas. 2009; 21(4):309–14.

Authors do not have any conflicts of interest to declare.