steroids in croup

Last edited 04/2019

In mild croup (seal-like barking cough - however no stridor or sternal/intercostal recession at rest/respiratory distress)

• a sytematic review has suggested that a a single dose of oral dexamethasone (0.15 mg/kg) to be taken immediately is of benefit in mild croup (1) compared with placebo.

Evidence base (1,2):

• mild croup (1)
  • single oral dose of dexamethasone improves symptoms in children with mild croup, compared with placebo
  • humidification is often used in children with mild to moderate croup, but no RCT evidence to support its use in clinical practice
• moderate to severe croup (1)
  • intramuscular or oral dexamethasone, nebulised adrenaline (epinephrine), and nebulised budesonide reduce symptoms compared with placebo
  • oral dexamethasone is as effective as nebulised budesonide at reducing symptoms
    • a dexamethasone dose of 0.15 mg/kg may be as effective as a dose of 0.6 mg/kg
    • addition of nebulised budesonide to oral dexamethasone does not seem to improve efficacy compared with either drug alone
  • unknown if heliox (helium-oxygen mixture) or humidification are beneficial in children with moderate to severe croup
    
    
• the Cochrane review noted (2):
  • glucocorticoids reduced symptoms of croup at two hours, shortened hospital stays, and reduced the rate of return visits to care
  • uncertainty remains with regard to the optimal type, dose, and mode of administration of glucocorticoids for reducing croup symptoms in children
    • no significant difference in length of stay in the hospital or emergency department between children treated with dexamethasone compared to budesonide, or with dexamethasone compared to prednisolone
    • compared to those treated with betamethasone, children treated with dexamethasone were at a significantly increased risk for needing epinephrine
    • no significant difference between children treated with dexamethasone and those treated with prednisolone in the need for epinephrine or supplemental glucocorticoids
    • with respect to use of steroids in mild croup the review noted that
      • three studies included children with mild croup (Bjornson 2004; Geelhoed 1996; Luria 2001). Sample sizes tended to be small with a median of 72 (interquartile range (IQR) 54 to 99) children
        • Bjornson et al noted that for children with mild croup, dexamethasone is an effective treatment that results in consistent and small but important clinical and economic benefits (3)

Reference:

1. Johnson DW. Croup. BMJ Clin Evid. 2014; 2014: 0321
2. Gates A et al. Glucocorticoids for croup in children.Cochrane Database Syst Rev. 2018 Aug 22;8:CD001955
3. Bjornson CL et al. A randomized trial of a single dose of oral dexamethasone for mild croup. N Eng J Med 2004; 351:1306-13.