Question

• In pediatric patients with croup, are glucocorticoids more effective than placebo in improving symptoms?

Clinical Bottom Lines

1. Acute laryngotracheobronchitis is a very common cause of upper airway obstruction in children and has an annual incidence of 1.5% to 6% in children under 6 years of age. 
2. Meta-analysis of 24 randomized, controlled studies support the use of glucocorticoids for treatment of croup. Findings suggest an improvement in symptoms at 6 hours after treatment and continued improvement in symptoms up to 24 hours.  The study also finds that treatment with glucocorticoids compared with placebo decreased the length of time in the ER and decreased the need for additional treatments such as epinephrine.

Summary of Key Evidence

1. Meta-analysis of 24 randomized controlled studies were analyzed and outcome measures were standardized using statistical methods.¹  The 24 studies all examined pediatric patients w/ croup who had received glucocorticoids vs. placebo. The meta-analysis compared the symptomatic improvement after treatment with a glucocorticoid compared with placebo at 6, 12 and 24 hours from baseline. 
2. Significant improvement in symptoms was noted as early as 6 hours after treatment. Confidence intervals and number needed to treat were calculated and found that at 6 hours the number needed to treat was 7 and at 12 hours was 5. 
3. The findings suggest no change in hospitalization rate, intubation/tracheotomy, or rate of supplemental glucocorticoid usage.
4. Publication bias may be associated with fewer articles being chosen for the meta-analysis with statistically negative results, which may result in less significant outcomes.

Additional Comments

• The use of once only dosage of glucocorticoids is associated with minimal side effects and toxicity when given acutely.
• No attempt was made in this study to differentiate outcomes between different routes of medication administration.

Citation

1. Ausejo M, Saenz B, Kellner J, Johnson D, Moher D, and Klassen T.   The effectiveness of glucocorticoids in treating croup: meta analysis BMJ 1999; 319: 595-599.

CAT Author: Karen Brenner, MD

CAT Appraisers: John Frohna, MD

Date appraised: November 1, 1999