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Dose of dexamethasone in croup

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 stayNo 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 hoursNo clinical or statistical difference0.6mg/kg, 2/30 children

0.3mg/kg, 2/60 children

0.15mg/kg, 1/30 children
Use of nebulized adrenalineNo 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 scoresNo clinical or statistical difference
Re-presented with croupNo 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.