Review: Glucocorticoids improve symptoms of croup within 6 hours
Ausejo M, Saenz A, Ba' Pham, Kellner JD, Johnson DW, Moher D,
et al. The effectiveness of glucocorticoids in treating croup: meta-analysis. BMJ 1999;319:595-600
Question
In children with croup, what is the effectiveness of
glucocorticoids on croup severity, length of hospital stay, and
need for additional interventions?
Data sources
Studies were identified by searching Medline (1966 to August
1997), EMBASE/Excerpta Medica (1974 to August 1997), and the Cochrane
Library Controlled Trials Register. Authors of trials published in the
past 5 years were contacted.
Study selection
Studies were selected if they were randomised controlled
trials of glucocorticoids compared with placebo or another active
treatment in patients with croup and if clinically relevant outcome
measures were used (clinical score, length of hospital stay, or need
for additional interventions).
Data extraction
Data were extracted on patient characteristics, details
about the intervention and control, and outcomes. The main
outcome measure was improvement from baseline croup score. Additional
outcomes were length of stay in the hospital or emergency department,
rate of hospitalisation, and use of additional interventions.
Main results
Twenty four studies were included; 19 were placebo controlled. Age
ranged from 4 months to 12 years (mean range 13 to 45 months).
Seventeen trials evaluated dexamethasone, 9 evaluated budesonide, and 3
evaluated methylprednisolone. Improvement in croup score was measured
at 6 hours in 13 studies, 12 hours in 7 studies,
and 24 hours in 5 studies. The pooled effect sizes (ESs) showed an
improvement in croup score with glucocorticoids at 6 hours (pooled ES
1.0, 95% CI 0.6 to 1.5) and 12 hours (pooled ES 1.0, CI 0.4 to 1.6).
At 24 hours the improvement in croup score did not reach statistical
significance (pooled ES 1.0, CI —0.1 to 2.0). When children were
assessed as clinically improved or not glucocorticoids showed a benefit
at all three time points (Table). The use of adrenaline as an
additional intervention decreased in children who received
glucocorticoids (absolute decrease of 9% in budesonide recipients and
12% in dexamethasone recipients [number needed to treat of 10]).
Additional use of antibiotics or supplemental glucocorticoids did not
increase. Children who received glucocorticoids spent less time in the
emergency department (weighted mean decrease 11 hours, CI 4 to 18) and
inpatients spent less time in the hospital (weighted mean decrease 16
hours, CI 1 to 31). The use of glucocorticoids did not affect the rate
of hospitalisation.
Glucocorticoids versus placebo for clinical improvement in children with croup*
| Time point |
Number of studies |
Weighted event rates |
|
| |
| Glucocorticoids |
Placebo |
RBI (95% CI) |
NNT (CI) |
| |
| 6 h |
13 |
56% |
41% |
37% (6 to 56) |
7 (4 to 50) |
| |
| 12 h |
7 |
89% |
68% |
31% (16 to 43) |
5 (3 to 11) |
| |
| 24 h |
59 |
5% |
83% |
14% (4 to 24) |
8 (5 to 33) |
| |
| *Abbreviations defined in glossary; RBI, NNT, and CI calculated from data in article. |
Conclusion
In children with croup, glucocorticoids relieve symptoms of
croup within 6 hours of treatment.
Notes
Funding: in part, Health Research Fund from the government of Spain.
EBM-Commentary
The review by Ausejo and colleagues shows glucocorticoids
to be superior to placebo in ameliorating symptoms of croup at 6 and 12
(but not 24) hours after administration and in diminishing the need for
inhaled adrenaline. The effect of the reviewed drugs might also apply
to other preparations (eg prednisone suppositories, which are used in
central Europe).1
The review used meta-analysis to examine the effectiveness of
glucocorticoids. The individual clinical relevance depends on the
baseline severity, which was not given for the pooled data. It can be
shown, however, from a typical study2: croup patients at
baseline had a mean of 3.8 points on the Westley croup score, and after
5 hours the 2 intervention groups had decreases of 2.0 to 2.9 points
compared with a 1.3 point decrease in the placebo group. The children
in the studies in this meta-analysis were moderately ill. They improved
in the croup specific score, but a greater benefit was seen when they
were assessed for clinical improvement.
Nebulised budesonide and oral and parenteral dexamethasone (less
expensive with no difference in efficacy) can be recommended for acute
croup in children. Close monitoring is necessary during the first day
of glucocorticoid treatment, however, because such treatment does not
substantially lower the hospitalisation rate.
Croup occasionally affects one child several times and might occur on a
hereditary basis.3 Thus, the early parental administration
of glucocorticoids to children with recurrent croup or to their
siblings having a first episode should be evaluated to see whether it
lowers the need for emergency visits or hospitalisation.
Johannes Forster MD St Josefskrankenhaus, Freiburg, Germany
- Zach MS, Modl M. Monatsschr Kinderheilkd 1998;146:914-23.
- Johnson DW, Jacobson S, Edney PC, et al. N Engl J Med 1998;339:498-503.
- Camilla AE, Holberg CJ, Wright AL, et al. Pediatr Pulmonol 1993;16:275-80.
studentBMJ 2000;08:259-302 August ISSN 0966-6494
