G95(P) Best practice: one or two doses of dexamethasone for the treatment of croup?

Abstract

Aim A systematic review of 43 randomised controlled trials (RCTs) concluded that single dose oral dexamethasone is effective in the treatment of croup. Dexamethasone was associated with an improved Westley score at 6 h to 12 h with an effect size of –1.0 (95% CI –1.5 to –0.6) which was significant, but was no longer significant at 24 h. To date, no RCTs have determined whether administering two doses of dexamethasone, compared with a single dose, improves outcomes in children with croup. We completed an audit to review the use of dexamethasone in children with croup. Method Inpatient notes of 50 children admitted between 2010 and 2011 were reviewed at a district general hospital. To gauge the readmission rate, a comparative notes review was performed for attendances at the Emergency Department of a local tertiary paediatric centre (150 attendances, June–November 2014). Results Figure 1 shows results at the district general hospital Abstract G95(P) Figure 1 Half of the children who required readmission had the same croup score on their first admission and their second, implying that readmission was necessary due to lack of clinical improvement. At the tertiary centre, 90% (135) patients received a dose of dexamethasone on their first presentation and 10% (15) children re-attended. With 1 in 10 patients being readmitted despite one dose of dexamethasone, we conducted a regional survey of paediatricians in our deanery to assess baseline practice for multi-dose dexamethasone. The survey contained a hypothetical case scenario of a child with croup (stridor and chest wall retraction at rest) who received a dose of dexamethasone. At 12 h the patient improved with no symptoms at rest but symptoms on exertion. Respondents were given four management options, as shown in Table 1. A total of 112 responses were received, 44% from consultants. Abstract G95(P) Table 1 Responses from regional survey The results demonstrate a wide variation in practice. 23% of respondents stated that their choice was based on trust guidelines, whereas 77% stated it was personal practice. Conclusion The high readmission rate, variation in practice and lack of evidence for administering a second dose of dexamethasone in croup suggest this is a topic that would benefit from a research project.

Pediatric croup with COVID-19

“…Dexamethasone is used in croup as it improves symptoms, decreases hospital length of stay, and reduces return visit rates [ 18 ]. All three cases received multiple doses of dexamethasone, a therapeutic decision that is infrequent for our hospital's practice and is reserved for atypical cases not responding as expected to initial treatments [ 19 ]. Symptom scores with dexamethasone typically improve in 0.5 to 4 h [ 18 , 20 ].…”

Use of corticosteroids for croup in children

“…Previous anecdotal practice has advocated providing a second dose of steroids on discharge, which is to be taken 12 hours later at home after the first dose 12–15. However, there is currently no evidence to support the use of second dosing at home.…”

“…However, there is currently no evidence to support the use of second dosing at home. Moreover, the provision of this may risk a delay in returning to the hospital for review if a child is deteriorating 12–15…”

An Overview of the Effectiveness of Corticoids in Croup: A Systematic Literature Review

“…Hospitalized children with croup often receive multiple rounds of steroids, a practice that likely stems from an absence of inpatient-specific guidelines and a perception that multiple dosages may sustain the alleviation of symptoms and avert their return after initial improvements [7][8][9]. A recent investigation involving 327 hospitalized pediatric patients with croup discovered that about 48% were treated with multiday steroid regimens.…”