Croup

Clinical Scenario

A two-year-old child presents with a barking cough, stridor, and tachypnea.

Clinical Question

Are glucocorticoids effective in treating children with croup?

Evidence-Based Answer

Compared with placebo, treatment with glucocorticoids results in reduced symptoms, less need for treatment with racemic epinephrine, fewer readmissions to emergency departments, and shorter hospital stays.

Practice Pointers

Croup is an acute viral inflammation of the upper and lower respiratory tracts, characterized by inspiratory stridor, barking cough, subglottic swelling, and respiratory distress. Each year, croup occurs in up to 6 percent of children six months to six years of age.

Croup is self-limited, usually lasting four to seven days, but about one in 20 children with croup who present to emergency depart-ments requires hospitalization. (2)

Standard therapy for croup includes cool-mist humidification, hydration, supplemental oxygen, and general comfort measures. Nebulized racemic epinephrine improves symptoms and reduces respiratory fatigue, but these results are transient. Hospitalization is indicated in children with increasing or persistent respiratory distress, fatigue, cyanosis, or dehydration. In severe cases, patients may require intubation and mechanical ventilation. Stridor, cyanosis, sternal retraction, tachypnea, and tachycardia increase the risk for intubation. (3)

Most of the articles evaluated in this review used the Westley croup scoring system (4) to measure symptoms. This system assigns points for stridor, retractions, air entry, cyanosis, and level of consciousness. The use of glucocorticoids reduced symptom scores at six and 12 hours compared with placebo. In patients who received glucocorticoids, 69 percent improved at six hours, and 84 percent improved at 12 hours, compared with 46 percent and 61 percent, respectively, in patients who received placebo (number needed to treat [NNT], six to seven for both time intervals). Administration of glucocorticoids also led to fewer admissions or readmissions (NNT, 11), shorter emergency department and inpatient lengths of stay, and less need for racemic epinephrine.

There is insufficient research comparing the various glucocorticoids, or establishing the most effective glucocorticoid dosage and the most effective route of administration. Preliminary evidence suggests that oral and intramuscular dexamethasone may have equivalent efficacies, and that either may be more effective than nebulized dexametha-sone or budesonide. (5-7)

REFERENCES

(1.) Russell K, Wiebe N, Saenz A, Ausejo SM, Johnson D, Hartling L, et al. Glucocorticoids for croup. Cochrane Database Syst Rev 2004;(3):CD001955.

(2.) Knutson D, Aring A. Viral croup. Am Fam Physician 2004;69:535-40.

(3.) Jacobs S, Shortland G, Warner J, Dearden A, Gataure PS, Tarpey J. Validation of a croup score and its use in triaging children with croup. Anaesthesia 1994;49:903-6.

(4.) Westley CR, Cotton EK, Brooks JG. Nebulized racemic epinephrine by IPPB for the treatment of croup: a double-blind study. Am J Dis Child 1978;132:484-7.

(5.) Rittichier KK, Ledwith CA. Outpatient treatment of moderate croup with dexamethasone: intramuscular versus oral dosing. Pediatrics 2000;106:1344-8.

(6.) Luria JW, Gonzalez-del-Rey JA, DiGiulio GA, McAneney CM, Olson JJ, Ruddy RM. Effectiveness of oral or nebulized dexamethasone for children with mild croup. Arch Pediatr Adolesc Med 2001;155:1340-5.

(7.) Johnson DW, Jacobson S, Edney PC, Hadfield P, Mundy ME, Schuh S. A comparison of nebulized budesonide, intramuscular dexamethasone, and placebo for moderately severe croup. N Engl J Med 1998;339:498-503.

This clinical content conforms to AAFP criteria for evidence-based continuing medical education (EB CME). EB CME is clinical content presented with practice recommendations supported by evidence that has been systematically reviewed by an AAFP-approved source. The practice recommendations in this activity are available online at http://www.cochrane.org/cochrane/revabstr/AB003255.htm.

The Cochrane Abstract below is a summary of a review from the Cochrane Library. It is accompanied by an interpretation that will help clinicians put evidence into practice. William E. Cayley, Jr., M.D., M.Div., presents a clinical scenario and question based on the Cochrane Abstract, along with the evidence-based answer and a full critique of the abstract.

MICHAEL SCHOOFF, M.D., is associate director of the Clarkson Family Medicine Residency Program in Omaha. He received his medical degree from the Uniformed Services University of the Health Sciences, F. Edward Hebert School of Medicine, Bethesda, Md., and completed a family practice residency at Womack Army Medical Center, Fort Bragg, N.C.

Address correspondence to Michael Schooff, M.D., Clarkson Family Medicine, 4200 Douglas St., Omaha, NE 68131 (e-mail: mschooff@nebraskamed.org). Reprints are not available from the author.

COPYRIGHT 2005 American Academy of Family Physicians
COPYRIGHT 2005 Gale Group