Two-year-old Moyo is brought to the emergency department because her parents were concerned about noisy breathing.
You notice a barking cough, subcostal recessions, and stridor when she cries.
Her Westley Croup score is 3 (moderate).
You wonder what to prescribe to improve her symptoms and reduce the need for further treatment or admission.
What is croup?
When we hear a ‘barking seal-like cough,’ we often think of croup.
Croup is a common cause of stridor and upper airway obstruction in infants and toddlers (6-36 months). It often occurs in the winter and tends to be caused by viruses, with human parainfluenza being the usual culprit. Other viruses, such as RSV or SARS-CoV-2, are also potential causes. Most children can be discharged from the emergency department after a dose of corticosteroids and an appropriate safety net. However, hospitals vary in their use of corticosteroids, with different formulations and strengths used.
We’re not going to cover the management of life-threatening croup (which can be recognised in children with severe chest wall retractions, stridor at rest, or signs of respiratory failure). Moyo has moderate croup, and this blog post explores evidence supporting the use of corticosteroid for moderate croup.
Why give corticosteroids?
Much of the evidence in this blog is a translation of a recent 2023 Cochrane review of 45 randomised control trials involving 5888 children. When comparing corticosteroids to a placebo, children who received corticosteroids had a more significant reduction in croup scores between 2 and 12 hours of administration. They also had a shorter stay in the emergency department, a reduced length of hospital admission, and were much less likely to re-attend with croup.
Some clinicians recommend giving a second dose of corticosteroids on discharge, taken 12 hours after the initial dose. However, there is no evidence to support this practice, and it risks falsely reassuring parents and may lead to delays in returning to the hospital if the child deteriorates.
Single-dose corticosteroids effectively improve croup symptoms and may prevent the escalation of medical care, reduce emergency department and hospital admission stays, and reduce re-attendance rates.
Which corticosteroid should we give in croup?
The Cochrane review included 13 randomised controlled trials comparing different types of corticosteroids. There was enough evidence to draw conclusions only when comparing dexamethasone and prednisolone.
Dexamethasone was associated with fewer hospital admissions and return visits compared to prednisolone. Additionally, it is more palatable, better tolerated, and has fewer side effects.
How should we give the corticosteroids?
Five studies explored different routes of dexamethasone administration. When comparing oral dexamethasone to intramuscular (IM) dexamethasone, there was no difference in clinical improvement or the need for additional treatments. However, when oral dexamethasone was compared to nebulised corticosteroids, it led to a noticeable reduction in admission rates, re-attendances, and re-admissions.
IM or nebulised corticosteroids may be more distressing for children than oral, and this may exacerbate symptoms.
Oral dexamethasone is the most practical and effective route of administration of corticosteroids. Other routes can be cautiously considered if oral dexamethasone is not tolerated.
What dose of steroids should we give?
Dexamethasone dosing practices vary widely, ranging from 0.15 mg/kg to 0.6 mg/kg.
Four studies compared different doses. A higher dose did not reduce severity at two hours, although severity may have been lower at 24 hours. However, even if higher doses reduce severity at 24 hours, how important is this if patients don’t need to return? Similarly, the dosage used made little difference in the need for additional treatments or in the occurrence of medication side effects.
Overall, the evidence suggests that the efficiency of dexamethasone for moderate croup tails off at 0.15mg/kg. However, since studies have not shown any serious side effects from higher dexamethasone doses in children with severe croup who require nebulised adrenaline or airway management, it is reasonable to consider using higher doses in severe cases.
Moyo is prescribed a standard weight-based dose of 0.15mg/kg dexamethasone.
She tolerates this well, and after observation, her symptoms settle, and she is discharged home with her parents.
Take home points
Corticosteroids are more effective than a placebo for treating croup within the first 24 hours.
Dexamethasone is the most efficient, palatable, and best-tolerated corticosteroid.
Doses of 0.15mg/kg of dexamethasone are recommended regardless of the severity of croup. In children with life-threatening croup, consider higher doses of dexamethasone alongside nebulised adrenaline and airway management.
References
Hibberd O, Chylinska AA, Finn K, et al. Use of corticosteroids for croup in children. Archives of Disease in Childhood – Education and Practice. 2024. Published Online First: 15 April 2024. doi: 10.1136/archdischild-2023-326773
Aregbesola A, Tam CM, Kothari A, Le ML, Ragheb M, Klassen TP. Glucocorticoids for croup in children. Cochrane Database Syst Rev. 2023;1(1):CD001955. Published 2023 Jan 10. doi:10.1002/14651858.CD001955.pub5
National Institute for Health and Care Excellence. Croup [Internet]. NICE Clinical Knowledge Summaries. 2022 [cited 2023 Dec 29]. Available from: https://cks.nice.org.uk/topics/croup/
Laura Riddick. Croup, Don’t Forget the Bubbles, 2021. Available at:Â https://doi.org/10.31440/DFTB.32637
