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Three Part Question

In [a child with croup] is [low dose oral dexamethasone (0.15 mg/kg or 0.3 mg/kg) as good as 0.6 mg/kg] at [reducing croup score and length of stay]?

Clinical Scenario

A 2 year old child presents to the emergency department with respiratory distress and stridor. You suspect croup and want to include dexamethasone in the child's treatment. You wonder what dose of steroids is best to reduce symptoms and hospital length of stay.

Search Strategy

Ovid Medline 1950 to November week 3 2008
{[exp Dexamethasone/ or dexamethasone.mp or steroid.mp. or exp Steroids/ or glucocorticoid.mp. or exp Glucocorticoids/ or corticosteroid.mp] AND and [croup.mp. or exp Croup/ or laryngotracheobronchitis.mp]}

Search Outcome

222 papers were found of which one was found to be relevant.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Geelhoed GC, Macdonald WB, 1995, Australia	Paediatric ward patients with croup score >3. 60 patients randomised between single dose oral dexamethasone 0.6mg/kg and 0.3mg/kg 60 patients randomised between single dose oral dexamethasone 0.3mg/kg and 0.15mg/kg	RCT Level 2b	Median hospital stay	No clinical or statistical statistical difference Median 7 – 9 hours for each group	Patients were excluded if their family did not speak English or they had no telephone. No information on method of randomisation or concealment. Eight children were not followed up after discharge. Exact numbers for each group not given. Results reported as % making data extraction difficult (for results seen here). Study was powered (at 80%) to detect a difference between groups of double the length of hospitalisation
			Hospitalized at 24 hours	No clinical or statistical difference0.6mg/kg, 2/30 children 0.3mg/kg, 2/60 children 0.15mg/kg, 1/30 children
			Use of nebulized adrenaline	No clinical or statistical difference 0.15mg/kg, 4/30 children 0.3mg/kg, 12/60 children 0.6mg/kg, 6/30 children
			Reduction in croup scores	No clinical or statistical difference
			Re-presented with croup	No clinical or statistical difference Not possible to extract exact numbers from text.

Comment(s)

Croup is a common diagnosis made in the emergency department. Steroids have become part of the standard treatment but the ideal dose is not known. This evidence shows that 0.15 mg/kg is just as effective. Geelhoed followed up this study with a placebo controlled study in mild croup giving 0.15 mg/kg to patients and showed it was effective in decreasing return visits to the ED.

Clinical Bottom Line

0.15 mg/kg dexamethasone appears to work as well as 0.3 mg/kg and 0.6 mg/kg at reducing croup score and need for nebulised adrenaline.

References

1. Geelhoed GC, Macdonald WB. Oral dexamethasone in the treatment of croup: 0.15 mg/kg versus 0.3 mg/kg versus 0.6 mg/kg. Pediatr Pulmonol. 1995;20(6):362-8.