The use of corticosteroids in croup: a survey

Trends in Incidence and Drug Prescriptions for Croup in Children Under 5 Years of Age: A 2002-2019 Population-Based Study

BACKGROUND

Tracking national croup trends can provide important insights for childhood health management. This study aimed to analyze the incidence and drug prescription trends in Korean children over a two-decade period.

METHODS

This population-based study encompassed 479,783 children aged < 5 years from 2002-2019, utilizing the National Health Insurance Service-National Sample Cohort. We identified participants with a primary croup diagnosis who were admitted to or visited the emergency room. Age-specific and age-adjusted incidence rates/10,000 person-years were calculated. We assessed using orthogonal polynomial contrasts and stratified by various factors (sex, age, residential area, economic status, comorbidities, and healthcare facility types). We observed changes in the use of five medications: inhaled steroids, systemic steroids, inhaled epinephrine, antibiotics, and short-acting bronchodilators. Generalized binomial logistic regression was used to analyze factors influencing prescription strategies.

RESULTS

In 2002, the croup-related visits were 16.1/10,000 person-years, increasing to 98.3 in 2019 (P for trend < 0.001). This trend persisted, regardless of age, sex, region, and economic status. Children with comorbid atopic dermatitis or asthma maintained consistent croup rates, while those without comorbidities increased. Treatment trends showed decreasing antibiotic (73-47%) and oxygen use (21.3-3.4%), with increasing nebulized epinephrine (9.3-41.5%) and multiple drug prescriptions (67.8-80.3%). Primary care centers exhibited a greater increase in prescription usage and hospitalization duration than did tertiary healthcare institutions.

CONCLUSION

Over the past two decades, croup incidence has risen, accompanied by increased epinephrine use and decreased antibiotic prescriptions. Longer hospitalization and higher medication use were mainly observed in primary care facilities.

Comparison between single-dose oral prednisolone and oral dexamethasone in the treatment of croup: a randomized, double-blinded clinical trial

OBJECTIVE

To compare the effectiveness of three corticosteroid regimens in children with mild to moderate croup.

METHODS

Double-blinded, randomized comparative trial with parallel design, conducted in the ED of a paediatric tertiary care hospital. Children aged 6 months to 6 years presenting to the ED with croup were eligible for inclusion if their Westley croup score was 2 or more. They were randomized to receive a single oral dose of either prednisolone 1 mg/kg, dexamethasone 0.15 mg/kg or dexamethasone 0.6 mg/kg. Primary outcome measures were the magnitude and rate of reduction in Westley croup score, rate of return for medical care with ongoing croup, and further treatment with steroids in the week following index presentation. Secondary outcome measures were the proportion of subjects requiring admission or salvage therapy, such as nebulized adrenaline, during index presentation.

RESULTS

A total of 99 children, aged 6-79 months, were enrolled (mean age: 1.7 years). Thirty-four patients were randomized to receive prednisolone 1 mg/kg, 34 to receive dexamethasone 0.15 mg/kg, and 31 to receive dexamethasone 0.6 mg/kg. Baseline characteristics of the three groups were similar. The parents of 86 patients (87%) were available for follow-up telephone interview at 1 week. There were no significant differences in primary or secondary outcome measures between the three treatment groups.

CONCLUSIONS

Both prednisolone 1 mg/kg and low-dose dexamethasone (0.15 mg/kg) were found not to differ in efficacy from the currently recommended 0.6 mg/kg dexamethasone. The use of these corticosteroid regimens in treating patients with mild to moderate croup is thus supported.

Out-of-hospital cardiopulmonary arrest in children with croup

Viral laryngotracheobronchitis is a ubiquitous infectious process that has not caused significant mortality in the past 20 years. Bacterial tracheitis and pneumonia can complicate viral laryngotracheobronchitis and markedly increase the risk of bad outcome. Even uncomplicated, properly managed, viral laryngotracheobronchitis can occasionally result in death, particularly in the infant age group.

Outpatient treatment of moderate croup with dexamethasone: intramuscular versus oral dosing

OBJECTIVE

Steroid use for the treatment of croup has been supported by several studies, although few have addressed the use of oral dexamethasone for outpatient management. The efficacy of oral (PO) versus intramuscular (IM) dosing of dexamethasone in the outpatient treatment of moderate croup are compared in this study.

METHODS

Patients between the ages of 3 months and 12 years with moderate croup (history or presence of stridor, cyanosis, or retractions) were eligible for enrollment in this single-blind, prospective study. Patients were randomized to receive a single dose (0.6 mg/kg, maximum 8 mg) of IM or PO dexamethasone. Parents were contacted by phone to assess resolution of symptoms and need for further evaluation.

RESULTS

Two hundred seventy-seven patients were enrolled (median age: 2.1 years). One hundred thirty-nine patients received IM dexamethasone, and 138 received PO. At phone follow-up, 141 (51%) had total resolution of symptoms (75 in IM, 66 in PO). Eighty patients (29%) returned for further evaluation (45 in IM, 35 in PO). Twenty-three (8%) received either more steroids, racemic epinephrine, or admission (11 in IM, 12 in PO).

CONCLUSION

No statistically significant difference was found in the need for subsequent interventions after a single dose of either IM or PO dexamethasone. A single PO dose of dexamethasone can be effectively and safely used for the outpatient treatment of moderate croup.

[Childhood croup]

Hoarseness, whooping cough and stridor are elements of a syndrome of upper airway obstruction. In childhood, acute laryngotracheobronchitis is by far the commonest cause of this syndrome. Yet, the differential diagnosis includes a number of rare and severe entities. In many cases, the traditional distinction between viral and spasmodic types is not possible. The value of humidifying therapy has not been established. In severe cases, nebulized adrenaline is of benefit but should be reserved for hospital. The effect lasts only two hours and at times a rebound effect is observed. It is now realized that some patients treated with adrenaline can safely be discharged after a two to three hours observation. There is a large body of evidence that all children arriving at the emergency department with croup should receive steroids without delay. This policy results in a much better outcome, with important reduction in hospitalizations, intensive care unit admissions and incubations. Oral dexamethasone is the drug of choice: it is as effective, easier to administer and cheaper than nebulised budesonide. In most studies, dexamethasone has been used at a dose of 0.6 mg/kg but there is some evidence that 0.15 mg/kg may be just as effective.

Croup

The management of mild to severe croup has undergone dramatic changes in the last 5 years, primarily due to the increased understanding of the benefits of treating it with steroids. Steroids have been used in the treatment of croup for many years, but, until recently, their use has remained controversial. Earlier studies were often not blinded or used inappropriate outcome measures, such as respiratory rate, which have not proven appropriate. Two attempts to review the literature in 1980 and 1989 cautiously supported the use of steroids. Despite these recommendations many practitioners continued to view croup in most cases as a benign self-limited condition, and since steroids have potential side-effects, their use was not considered justified. More recently, however, a number of developments such as the successful use of the inhaled steroid budesonide and oral dexamethasone have reinforced the argument for using steroids. Recent work has also shown that both inhaled and systemic steroids work by 1 hour and dramatically reduce morbidity and hospitalization time. The demonstration that an oral dose of 0.15 mg/kg dexamethasone is as effective as larger doses has made the use of systemic steroids more acceptable to many practitioners. All children with croup severe enough to be admitted to hospital should receive steroids. Two recent studies have shown that steroids also benefitted children who presented to emergency departments for treatment, but whose croup was not considered severe enough for admission. The type of steroid, the dose, and the mode of administration will need to be decided by the attending clinician.

Sixteen years of croup in a Western Australian teaching hospital: effects of routine steroid treatment

STUDY OBJECTIVE

To describe the experience of croup at Princess Margaret Hospital for Children (PMH), the only tertiary pediatric hospital in Western Australia, from 1980 through 1995 with reference to the introduction of routine steroid treatment in the ICU in 1989, in the general hospital wards from 1989 through 1993, and in the emergency department observation ward in 1993.

METHODS

Information on the numbers of children with croup presenting to PMH from 1980 through 1985 who were admitted to the general wards, the ICU, and the observation ward; intubation rate; and length of stay was obtained from a combination of state health records, hospital statistics, logbooks, and computer records.

RESULTS

The numbers of children who presented to and were admitted to PMH with croup were similar for all years of the study period. Since 1989, the annual number of children intubated (1980-1989 average, 8; 1990-1995 average, 4) and total ICU days for croup (1980-1989 average, 129; 1990-1995 average, 24) has decreased dramatically. The annual percentage of children transferred to the ICU (1980-1989 average, 11.6%; 1994-1995 average, 2.6%) and the average length of stay for PMH (1980-1989 average, 2.03 days; 1994-1995 average, 1.1 days) decreased every year from 1989 through 1994, coincident with increasing use of steroids for croup in the general wards. The change of policy from no steroids to compulsory use of steroids in the observation ward coincided with an increase in the percentage of children discharged home directly from the observation ward (to 97% from 80%).

CONCLUSION

The introduction of steroids at PMH coincided with a dramatic decrease in measures of severity for children admitted to hospital with mild to severe croup. All children hospitalized with croup should receive steroid therapy.

Infraglottic and bronchial infections

Concerns over infraglottic and bronchial infections have been a source of anxiety and lost sleep for many children, parents, and physicians. The annual incidence of lower respiratory tract infections in children younger than 6 years old exceeds 5 million in the United States. Despite the frequency of these infections, the often common and nonspecific clinical symptomatology, variable severity, and changing epidemiology over time all have contributed to our understanding and misunderstanding of these disorders.

Efficacy of a small single dose of oral dexamethasone for outpatient croup: a double blind placebo controlled clinical trial

OBJECTIVE

To assess the efficacy of a single dose of oral dexamethasone 0.15 mg/kg in children with mild croup not admitted to hospital.

DESIGN

Double blind, randomised, placebo controlled clinical trial.

SETTING

The emergency department of a tertiary paediatric hospital.

SUBJECTS

100 children aged 4-122 months presenting with mild croup.

INTERVENTION

A single oral dose of dexamethasone 0.15 mg/kg or placebo.

MAIN OUTCOME MEASURE

Return to medical care with ongoing croup.

RESULTS

Baseline characteristics of the two treatment groups were similar. Eight children (all from the placebo group) returned to medical care with ongoing croup, one being admitted. There was no reported difference in duration of croup symptoms, duration of viral symptoms, or rate of return to medical care for other reasons.

CONCLUSION

Oral dexamethasone in a dose of 0.15 mg/kg is effective in reducing return to medical care with ongoing croup in children with mild croup.