REVIEW QUESTION

Are glucocorticoids effective in the treatment of croup in children?

TYPE OF REVIEW

A systematic review of 43 studies, including 4,565 children.

RELEVANCE FOR NURSING

Croup accounts for most clinic and ED visits for respiratory tract infection in children. Diagnosis is based on symptoms, especially the characteristic harsh, barking cough. Croup causes edema and narrowing of the larynx, trachea, and bronchi, making it hard for the child to breathe.

Croup is commonly caused by the parainfluenza virus. 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 results are transient. Hospitalization is indicated for children with increasing or persistent respiratory distress, fatigue, cyanosis, or dehydration. In severe cases, children may require intubation and mechanical ventilation. Because glucocorticoids decrease airway inflammation and edema, children with croup symptoms are often given glucocorticoids to help prevent croup from worsening.

CHARACTERISTICS OF THE EVIDENCE

This review assessed the effectiveness of glucocorticoids in the treatment of croup in children to determine if they reduced croup symptoms, decreased return visits or readmissions, shortened hospital or ED lengths of stay, reduced the need for additional treatments, or had adverse effects.

The review included 43 studies published between 1964 and 2013, for a total of 4,565 children ages zero to 18 years. The glucocorticoids investigated were beclomethasone, betamethasone, budesonide, dexamethasone, fluticasone, and prednisolone. The authors measured the effects of glucocorticoids, alone or in combination, compared with placebo or another drug treatment. The primary outcomes were change in croup score at two, six, 12, and/or 24 hours and return care visits or hospital (re)admissions or both. Secondary outcomes included hospital or ED length of stay; patient improvement at two, six, 12, and/or 24 hours; use of additional treatments; and adverse events.

Glucocorticoids improved croup symptoms at two hours and the effect lasted at least 24 hours. Glucocorticoids reduced rates of return care visits and hospital (re)admissions. Glucocorticoids also reduced length of stay by 15 hours (range, 6 to 24 hours) but made no difference in the need for additional treatments. Study results did not point to which type, amount, and administration mode (oral, inhaled, or injected) of glucocorticoids was best in reducing symptoms of croup in children. Few serious adverse events were reported.

BEST PRACTICE RECOMMENDATIONS

For children with croup, glucocorticoids are effective in reducing symptoms at two hours after treatment, and this benefit may last at least 24 hours. For these children, glucocorticoid treatment reduces hours spent in the hospital or ED, as well as the rate of return visits or readmissions or both. While dexamethasone is the mainstay of treatment for croup in children, this review showed that budesonide is an effective alternative. Data were insufficient to draw conclusions about the role of other glucocorticoids in reducing the symptoms of croup.

RESEARCH RECOMMENDATIONS

Studies of the effectiveness of dexamethasone given via different modes of administration, and of different doses of dexamethasone and budesonide, are warranted. Additional analyses should evaluate the comparative effectiveness of different glucocorticoids in light of the paucity of head-to-head trials. Trials that compare one and multiple days of glucocorticoid treatment would also be of interest. Research is required to identify barriers to glucocorticoid treatment, and to establish effective strategies to narrow the evidence-to-practice gap.

REFERENCE