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Abstract
BACKGROUND Glucocorticoids are the mainstay for the treatment of croup. The existing evidence demonstrates that glucocorticoids are effective in the treatment of croup in children. However, updating the evidence on their clinical relevance in croup is imperative. This is an update to a review first published in 1999, and updated in 2004, 2011, and 2018. OBJECTIVES To investigate the effects and safety of glucocorticoids in the treatment of croup in children aged 18 years and below. SEARCH METHODS We searched the Cochrane Library, which includes the Cochrane Central Register of Controlled Trials (CENTRAL; 2022 Issue 9), Ovid MEDLINE Epub Ahead of Print, In-Process & Other Non-Indexed Citations and Ovid MEDLINE (1946 to 4 March 2022), Embase (Ovid) (1974 to 4 March 2022). We also searched the WHO ICTRP and ClinicalTrials.gov on 4 March 2022. SELECTION CRITERIA We included randomised controlled trials (RCTs) in children (aged 18 years and below) with croup. We assessed the effect of glucocorticoids compared to the following: placebo, any other pharmacologic agents, any other glucocorticoids, any combination of other glucocorticoids, given by different modes of administration, or given in different doses. The included studies must have assessed at least one of our primary outcomes (defined as the change in croup score or return visits, (re)admissions to the hospital or both) or secondary outcomes (defined as the length of stay in hospital or emergency departments, patient improvement, use of additional treatments, or adverse events). DATA COLLECTION AND ANALYSIS Review authors independently extracted data, with another review author verified. We entered the data into Review Manager 5 for meta-analysis. Two review authors independently assessed studies for risk of bias using the Cochrane risk of bias tool. Two review authors assessed the certainty of the evidence for the primary outcomes using the GRADE approach. MAIN RESULTS This updated review includes 45 RCTs with a total of 5888 children, an increase of two RCTs with 1323 children since the last update. We also identified one ongoing study and one study awaiting classification. We assessed most studies (98%) as at high or unclear risk of bias. Any glucocorticoid compared to placebo Compared to placebo, glucocorticoids may result in greater reductions in croup score after two hours (standardised mean difference (SMD) -0.65, 95% confidence interval (CI) -1.13 to -0.18; 7 RCTs, 426 children; low-certainty evidence); six hours (SMD -0.76, 95% CI -1.12 to -0.40; 11 RCTs, 959 children; low-certainty evidence); and 12 hours (SMD -1.03, 95% CI -1.53 to -0.53; 8 RCTs, 571 children; low-certainty evidence). The evidence for change in croup score after 24 hours is very uncertain (SMD -0.86, 95% CI -1.40 to -0.31; 8 RCTs, 351 children; very low-certainty evidence). One glucocorticoid compared to another glucocorticoid There was little to no difference between prednisolone and dexamethasone for reduction in croup score at two-hour post-baseline score (SMD 0.06, 95% CI -0.06 to 0.18; 1 RCT, 1231 children; high-certainty evidence). There was likely little to no difference between prednisolone and dexamethasone for reduction in croup score at six-hour post-baseline score (SMD 0.21, 95% CI -0.21 to 0.62; 1 RCT, 99 children; moderate-certainty evidence). However, dexamethasone probably reduced the return visits or (re)admissions for croup by almost half (risk ratio (RR) 0.55, 95% CI 0.28 to 1.11; 4 RCTs, 1537 children; moderate-certainty evidence), and showed a 28% reduction in the use of supplemental glucocorticoids as an additional treatment (RR 0.72, 95% CI 0.53 to 0.97; 2 RCTs, 926 children). Dexamethasone given in different doses Compared to 0.15 mg/kg, 0.60 mg/kg dexamethasone probably reduced the severity of croup as assessed by the croup scoring scale at 24-hour postbaseline score (SMD 0.63, 95% CI 0.16 to 1.10; 1 RCT, 72 children; moderate-certainty evidence); however, this was not the case at two hours (SMD -0.27, 95% CI -0.76 to 0.22; 2 RCTs, 861 children; high-certainty evidence). There was probably no reduction at six hours (SMD -0.45, 95% CI -1.26 to 0.35; 3 RCTs, 178 children; moderate-certainty evidence), and the evidence at 12 hours is very uncertain (SMD -0.60, 95% CI -4.39 to 3.19; 2 RCTs, 113 children; very low-certainty evidence). There was little to no difference between doses of dexamethasone in return visits or (re)admissions of children or both (RR 0.91, 95% CI 0.71 to 1.17; 3 RCTs, 949 children; high-certainty evidence) or length of stay in the hospital or emergency department (mean difference 0.12, 95% CI -0.32 to 0.56; 2 RCTs, 892 children). The need for additional treatments, such as epinephrine (RR 0.78, 95% CI 0.34 to 1.75; 2 RCTs, 885 children); intubation (risk difference 0.00, 95% CI -0.00 to 0.00; 2 RCTs, 861 children); or use of supplemental glucocorticoids (RR 0.77, 95% CI 0.51 to 1.15; 2 RCTs, 617 children), also did not differ between doses of dexamethasone. There were moderate to high levels of heterogeneity in the analyses for most comparisons. Adverse events were observed for some of the comparisons reported in the review. AUTHORS' CONCLUSIONS The evidence that glucocorticoids reduce symptoms of croup at two hours, shorten hospital stays, and reduce the rate of return visits or (re)admissions has not changed in this update. A smaller dose of 0.15 mg/kg of dexamethasone may be as effective as the standard dose of 0.60 mg/kg. More RCTs are needed to strengthen the evidence for effectiveness of low-dose dexamethasone at 0.15 mg/kg to treat croup.
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Affiliation(s)
- Alex Aregbesola
- Department of Pediatrics and Child Health, Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Canada
- Children's Hospital Research Institute of Manitoba, Winnipeg, Canada
| | - Clara M Tam
- Children's Hospital Research Institute of Manitoba, Winnipeg, Canada
| | - Asha Kothari
- Children's Hospital Research Institute of Manitoba, Winnipeg, Canada
| | - Me-Linh Le
- Neil John Maclean Health Sciences Library, University of Manitoba, Winnipeg, Canada
| | - Mirna Ragheb
- Children's Hospital Research Institute of Manitoba, Winnipeg, Canada
| | - Terry P Klassen
- Department of Pediatrics and Child Health, Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Canada
- Children's Hospital Research Institute of Manitoba, Winnipeg, Canada
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2
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Abstract
Croup refers to airway inflammation and edema leading to obstruction of the larynx, trachea, and bronchi. Croup is the most common cause of acute airway obstruction in young children. It is characterized by the onset of low-grade fever, barky cough, stridor, hoarseness, and respiratory distress. Croup is typically caused by a viral infection (viral croup) but can occur suddenly without a viral prodrome (spasmodic croup). Recurrent croup is defined as two or more episodes per year. Recurrent croup should be considered a symptom of an underlying structural or inflammatory airway abnormality and should prompt a work-up for the underlying cause.
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3
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Duse M, Santamaria F, Verga MC, Bergamini M, Simeone G, Leonardi L, Tezza G, Bianchi A, Capuano A, Cardinale F, Cerimoniale G, Landi M, Malventano M, Tosca M, Varricchio A, Zicari AM, Alfaro C, Barberi S, Becherucci P, Bernardini R, Biasci P, Caffarelli C, Caldarelli V, Capristo C, Castronuovo S, Chiappini E, Cutrera R, De Castro G, De Franciscis L, Decimo F, Iacono ID, Diaferio L, Di Cicco ME, Di Mauro C, Di Mauro C, Di Mauro D, Di Mauro F, Di Mauro G, Doria M, Falsaperla R, Ferraro V, Fanos V, Galli E, Ghiglioni DG, Indinnimeo L, Kantar A, Lamborghini A, Licari A, Lubrano R, Luciani S, Macrì F, Marseglia G, Martelli AG, Masini L, Midulla F, Minasi D, Miniello VL, Del Giudice MM, Morandini SR, Nardini G, Nocerino A, Novembre E, Pajno GB, Paravati F, Piacentini G, Piersantelli C, Pozzobon G, Ricci G, Spanevello V, Turra R, Zanconato S, Borrelli M, Villani A, Corsello G, Di Mauro G, Peroni D. Inter-society consensus for the use of inhaled corticosteroids in infants, children and adolescents with airway diseases. Ital J Pediatr 2021; 47:97. [PMID: 33882987 PMCID: PMC8058583 DOI: 10.1186/s13052-021-01013-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2021] [Accepted: 02/26/2021] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND In 2019, a multidisciplinary panel of experts from eight Italian scientific paediatric societies developed a consensus document for the use of inhaled corticosteroids in the management and prevention of the most common paediatric airways disorders. The aim is to provide healthcare providers with a multidisciplinary document including indications useful in the clinical practice. The consensus document was intended to be addressed to paediatricians who work in the Paediatric Divisions, the Primary Care Services and the Emergency Departments, as well as to Residents or PhD students, paediatric nurses and specialists or consultants in paediatric pulmonology, allergy, infectious diseases, and ear, nose, and throat medicine. METHODS Clinical questions identifying Population, Intervention(s), Comparison and Outcome(s) were addressed by methodologists and a general agreement on the topics and the strength of the recommendations (according to the GRADE system) was obtained following the Delphi method. The literature selection included secondary sources such as evidence-based guidelines and systematic reviews and was integrated with primary studies subsequently published. RESULTS The expert panel provided a number of recommendations on the use of inhaled corticosteroids in preschool wheezing, bronchial asthma, allergic and non-allergic rhinitis, acute and chronic rhinosinusitis, adenoid hypertrophy, laryngitis and laryngospasm. CONCLUSIONS We provided a multidisciplinary update on the current recommendations for the management and prevention of the most common paediatric airways disorders requiring inhaled corticosteroids, in order to share useful indications, identify gaps in knowledge and drive future research.
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Affiliation(s)
- Marzia Duse
- Department of Pediatrics, Policlinico Umberto I, Sapienza University of Rome, Rome, Italy
| | - Francesca Santamaria
- Department of Translational Medical Sciences, Federico II University, Naples, Italy.
| | | | | | | | - Lucia Leonardi
- Maternal, Infantile and Urological Sciences Department, Sapienza University, Rome, Italy
| | - Giovanna Tezza
- Pediatric Department, Franz Tappeiner Hospital, Meran, Italy
| | - Annamaria Bianchi
- Pediatric Unit, Department of Women's and Children's Health, San Camillo Forlanini Hospital, Rome, Italy
| | - Annalisa Capuano
- Department of Experimental Medicine, University "Luigi Vanvitelli", Regional Centre of Pharmacovigilance Campania, Naples, Italy
| | - Fabio Cardinale
- Pediatric and Emergency Unit Giovanni XXIII Pediatric Hospital University of Bari, Bari, Italy
| | | | - Massimo Landi
- Family Pediatrician Local Health Unit, Turin and IRIB-CNR, Palermo, Italy
| | | | | | - Attilio Varricchio
- Allergy Centre, Department of Pediatric Sciences IRCCS Gaslini Institute, Genova, Italy
| | - Anna Maria Zicari
- Departmental Operative Unit of Diagnostic and Surgical Videoendoscopy of the Upper Airways, Asl Napoli 1 Center, Naples, Italy
| | - Carlo Alfaro
- Maternal, infantile and urological sciences Department, Pediatric Allergic Unit, Sapienza University, Rome, Italy
| | - Salvatore Barberi
- Paediatrics Unit, Reunited Hospitals Castellammare of Stabia, Naples, Italy
| | | | | | - Paolo Biasci
- Pediatric Unit San Giuseppe Hospital, Empoli, Florence, Italy
| | - Carlo Caffarelli
- Family Paediatrician, Local Health Unit, FIMP National President, Livorno, Italy
| | - Valeria Caldarelli
- Department of Obstetrics Gynaecology and Pediatrics, Azienda USL-IRCCS di Reggio Emilia, Reggio Emilia, Italy
| | - Carlo Capristo
- Pediatric Unit, Department of Mother and Child, AUSL-IRCCS, Reggio Emilia, Italy
| | - Serenella Castronuovo
- Department of Woman, Child and of General and Specialized Surgery, University "Luigi Vanvitelli", Naples, Italy
| | - Elena Chiappini
- Family Paediatrician Local Health Unit Nettuno-Anzio, Rome, Italy
- Paediatric Infectious Disease Unit, Meyer Children's University Hospital, Department Of Health Sciences, University of Florence, Florence, Italy
| | - Renato Cutrera
- Pediatric Pulmonology Unit, Academic Department of Paediatrics, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Giovanna De Castro
- Departmental Operative Unit of Diagnostic and Surgical Videoendoscopy of the Upper Airways, Asl Napoli 1 Center, Naples, Italy
| | | | - Fabio Decimo
- Pediatric Unit, Department of Mother and Child, AUSL-IRCCS, Reggio Emilia, Italy
| | | | - Lucia Diaferio
- Department of Paediatrics, Aldo Moro University of Bari, Bari, Italy
| | - Maria Elisa Di Cicco
- Paediatrics Unit, University Hospital of Pisa, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Caterina Di Mauro
- General Paediatrics and Paediatric Acute and Emergency Unit, University Hospital San Marco, University of Catania, Catania, Italy
| | - Cristina Di Mauro
- Department of Experimental Medicine, University "Luigi Vanvitelli", Regional Centre of Pharmacovigilance Campania, Naples, Italy
| | - Dora Di Mauro
- Family Paediatrician Local Health Unit, Ausl, Modena, Italy
| | | | - Gabriella Di Mauro
- Department of Experimental Medicine, University "Luigi Vanvitelli", Regional Centre of Pharmacovigilance Campania, Naples, Italy
| | - Mattia Doria
- Primary Care Paediatrician, Local Health Unit, National Secretary for the Scientific and Ethical Activities of FIMP, Chioggia, Italy
| | - Raffaele Falsaperla
- Neonatal Intensive Care Unit and Neonatal Accompaniment Unit, University Hospital San Marco, University of Catania, Catania, Italy
| | - Valentina Ferraro
- Unit of Paediatric Allergy and Respiratory Medicine Women's and Children's Health Department, University Hospital Padua, Padua, Italy
| | - Vassilios Fanos
- Neonatal Intensive Care Unit, Neonatal Pathology and Neonatal Section, AOU and University of Cagliari, Monserrato (CA), Italy
| | - Elena Galli
- Pediatric Allergy Unit, Department of Paediatric Medicine, S. Pietro Hospital Fatebenefratelli, Rome, Italy
| | - Daniele Giovanni Ghiglioni
- Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico di Milano, UOSD Paediatric Highly Intensive Care Unit, Milan, Italy
| | - Luciana Indinnimeo
- Department of Pediatrics, Policlinico Umberto I, Sapienza University of Rome, Rome, Italy
| | - Ahmad Kantar
- Pediatric Asthma and Cough Center Istituti Ospedalieri Bergamaschi, Gruppo Ospedaliero San Donato, Ponte San Pietro, Bergamo, Italy
| | | | - Amelia Licari
- Paediatric and Neonatology Unit Santa Maria Goretti Hospital, Department of Pediatrics, University of Pavia, Pavia, Italy
| | - Riccardo Lubrano
- Paediatric and Neonatology Unit Santa Maria Goretti Hospital, Department of Pediatrics, Sapienza University, Rome, Italy
| | - Stefano Luciani
- Pediatric and Neonatal Intensive Care Unit Fatebenefratelli Isola Tiberina, Rome, Italy
| | - Francesco Macrì
- Allergist Pediatrician National Secretary of Italian Federation for Medical Scientific Societies (FISM), Rome, Italy
| | - Gianluigi Marseglia
- Paediatric and Neonatology Unit Santa Maria Goretti Hospital, Department of Pediatrics, University of Pavia, Pavia, Italy
| | | | - Luigi Masini
- Pediatric Pulmonology and Subintensive Respiratory Therapy Unit Department of Pediatrics Santobono-Pausilipon Children's Hospital, Naples, Italy
| | - Fabio Midulla
- Maternal, Infantile and Urological Sciences Department, Sapienza University, Rome, Italy
| | - Domenico Minasi
- Pediatric Unit Great Metropolitan Hospital Reggio Calabria, Reggio Calabria, Italy
| | - Vito Leonardo Miniello
- Department of Biomedical Science and Human Oncology, University of Bari, Children's Hospital "Giovanni XXIII", Bari, Italy
| | | | | | | | - Agostino Nocerino
- Department of Translational Medical Sciences, Pediatric Pulmonology, Federico II University, Naples, Italy
| | - Elio Novembre
- Division of Pediatrics, University Hospital of Udine, Udine, Italy
| | | | - Francesco Paravati
- Department of Human Pathology in Adult and Development Age, Pediatric Unit, University of Messina, Messina, Italy
| | | | - Cristina Piersantelli
- Paediatric Section Department of Surgery, Dentistry, Paediatrics and Gynaecology University of Verona, Verona, Italy
| | - Gabriella Pozzobon
- Family Pediatrician, Paediatric Allergy, Local Health Unit TO1, Turin, Italy
| | | | | | - Renato Turra
- Family Pediatrician Local Health Unit, Caselle Torinese, Vicenza, Italy
| | | | - Melissa Borrelli
- Department of Translational Medical Sciences, Federico II University, Naples, Italy
| | - Alberto Villani
- Unit of Pediatric Allergy and Respiratory Medicine Women's and Children's Health Department University Hospital, Padua, Italy
| | | | | | - Diego Peroni
- Department of Clinical and Experimental Medicine, Section of Pediatrics, University of Pisa, Pisa, Italy
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Parker CM, Cooper MN. Prednisolone Versus Dexamethasone for Croup: a Randomized Controlled Trial. Pediatrics 2019; 144:peds.2018-3772. [PMID: 31416827 DOI: 10.1542/peds.2018-3772] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/17/2019] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVES The use of either prednisolone or low-dose dexamethasone in the treatment of childhood croup lacks a rigorous evidence base despite widespread use. In this study, we compare dexamethasone at 0.6 mg/kg with both low-dose dexamethasone at 0.15 mg/kg and prednisolone at 1 mg/kg. METHODS Prospective, double-blind, noninferiority randomized controlled trial based in 1 tertiary pediatric emergency department and 1 urban district emergency department in Perth, Western Australia. Inclusions were age >6 months, maximum weight 20 kg, contactable by telephone, and English-speaking caregivers. Exclusion criteria were known prednisolone or dexamethasone allergy, immunosuppressive disease or treatment, steroid therapy or enrollment in the study within the previous 14 days, and a high clinical suspicion of an alternative diagnosis. A total of 1252 participants were enrolled and randomly assigned to receive dexamethasone (0.6 mg/kg; n = 410), low-dose dexamethasone (0.15 mg/kg; n = 410), or prednisolone (1 mg/kg; n = 411). Primary outcome measures included Westley Croup Score 1-hour after treatment and unscheduled medical re-attendance during the 7 days after treatment. RESULTS Mean Westley Croup Score at baseline was 1.4 for dexamethasone, 1.5 for low-dose dexamethasone, and 1.5 for prednisolone. Adjusted difference in scores at 1 hour, compared with dexamethasone, was 0.03 (95% confidence interval -0.09 to 0.15) for low-dose dexamethasone and 0.05 (95% confidence interval -0.07 to 0.17) for prednisolone. Re-attendance rates were 17.8% for dexamethasone, 19.5% for low-dose dexamethasone, and 21.7% for prednisolone (not significant [P = .59 and .19]). CONCLUSIONS Noninferiority was demonstrated for both low-dose dexamethasone and prednisolone. The type of oral steroid seems to have no clinically significant impact on efficacy, both acutely and during the week after treatment.
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Affiliation(s)
- Colin M Parker
- Perth Children's Hospital, Perth, Australia; .,Joondalup Health Campus, Perth, Australia; and
| | - Matthew N Cooper
- Telethon Kids Institute, The University of Western Australia, Perth, Australia
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Fernandes RM, Wingert A, Vandermeer B, Featherstone R, Ali S, Plint AC, Stang AS, Rowe BH, Johnson DW, Allain D, Klassen TP, Hartling L. Safety of corticosteroids in young children with acute respiratory conditions: a systematic review and meta-analysis. BMJ Open 2019; 9:e028511. [PMID: 31375615 PMCID: PMC6688746 DOI: 10.1136/bmjopen-2018-028511] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2018] [Revised: 06/24/2019] [Accepted: 07/03/2019] [Indexed: 12/12/2022] Open
Abstract
OBJECTIVE Adverse events (AEs) associated with short-term corticosteroid use for respiratory conditions in young children. DESIGN Systematic review of primary studies. DATA SOURCES Medline, Cochrane CENTRAL, Embase and regulatory agencies were searched September 2014; search was updated in 2017. ELIGIBILITY CRITERIA Children <6 years with acute respiratory condition, given inhaled (high-dose) or systemic corticosteroids up to 14 days. DATA EXTRACTION AND SYNTHESIS One reviewer extracted with another reviewer verifying data. Study selection and methodological quality (McHarm scale) involved duplicate independent reviews. We extracted AEs reported by study authors and used a categorisation model by organ systems. Meta-analyses used Peto ORs (pORs) and DerSimonian Laird inverse variance method utilising Mantel-Haenszel Q statistic, with 95% CI. Subgroup analyses were conducted for respiratory condition and dose. RESULTS Eighty-five studies (11 505 children) were included; 68 were randomised trials. Methodological quality was poor overall due to lack of assessment and inadequate reporting of AEs. Meta-analysis (six studies; n=1373) found fewer cases of vomiting comparing oral dexamethasone with prednisone (pOR 0.29, 95% CI 0.17 to 0.48; I2=0%). The mean difference in change-from-baseline height after one year between inhaled corticosteroid and placebo was 0.10 cm (two studies, n=268; 95% CI -0.47 to 0.67). Results from five studies with heterogeneous interventions, comparators and measurements were not pooled; one study found a smaller mean change in height z-score with recurrent high-dose inhaled fluticasone over one year. No significant differences were found comparing systemic or inhaled corticosteroid with placebo, or between corticosteroids, for other AEs; CIs around estimates were often wide, due to small samples and few events. CONCLUSIONS Evidence suggests that short-term high-dose inhaled or systemic corticosteroids use is not associated with an increase in AEs across organ systems. Uncertainties remain, particularly for recurrent use and growth outcomes, due to low study quality, poor reporting and imprecision.
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Affiliation(s)
- Ricardo M Fernandes
- Pediatrics, Hospital de Santa Maria, Lisbon, Portugal
- Faculty of Medicine, Instituto de Medicina Molecular, University of Lisbon, Laboratory of Clinical Pharmacology and Therapeutics, Lisbon, Portugal
| | - Aireen Wingert
- Alberta Research Centre for Health Evidence, Pediatrics, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - Ben Vandermeer
- Alberta Research Centre for Health Evidence, Pediatrics, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - Robin Featherstone
- Alberta Research Centre for Health Evidence, Pediatrics, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - Samina Ali
- Pediatrics, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
- Women & Children's Health Research Institute, Pediatrics, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - Amy C Plint
- Pediatrics, Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Antonia S Stang
- Pediatrics, Emergency Medicine, and Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Brian H Rowe
- Emergency Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
- School of Public Health, University of Alberta, Edmonton, Alberta, Canada
| | - David W Johnson
- Pediatrics, Emergency Medicine, and Physiology and Pharmacology, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Dominic Allain
- Pediatrics, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - Terry P Klassen
- Manitoba Institute of Child Health, Faculty of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Lisa Hartling
- Alberta Research Centre for Health Evidence, Pediatrics, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
- Pediatrics, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
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6
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Ali S, Moodley A, Bhattacharjee A, Chang E, Kabaroff A, Lobay K, Allain D. Prehospital dexamethasone administration in children with croup: a medical record review. Open Access Emerg Med 2018; 10:141-147. [PMID: 30410413 PMCID: PMC6200067 DOI: 10.2147/oaem.s168728] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Objectives Croup is one of the most common childhood respiratory illnesses. Early dexamethasone administration in croup can improve patient outcomes. The objective of this study was to assess the clinical impact of prehospital administration of dexamethasone to children with croup. Methods A medical record review that included children between 6 months and 6 years, who were brought via emergency medical services (EMS) to the emergency department (ED) with a final diagnosis of croup, between January 2010 and December 2012, was conducted. Data were collected regarding prehospital management and ED management, length of stay (LOS), final disposition, and patient demographics. Results A total of 188 patients with an ED diagnosis of croup were enrolled, 35.1% (66/188) of whom received a prehospital diagnosis of croup. The mean age of the participants was 32.96±17.18 months and 10.6% (20/188) were given dexamethasone in the prehospital setting by EMS, while 30.3% (57/188) were given epinephrine nebulizations. Out of the 66 patients with a prehospital diagnosis of croup, 10.6% (7/66) were given dexamethasone by EMS. In ED, dexamethasone was administered to 88.3% (166/188) while 29.8% of participants (56/188) received epinephrine nebulizations. There was no significant difference in ED LOS between those who received prehospital dexamethasone (2.6±1.6 hours, n=18) and those who did not (3.3±2.7 hours, n=159) (P=0.514). The number of in-hospital epinephrine doses per patient was significantly influenced by the administration of prehospital dexamethasone (P=0.010). Conclusions Prehospital administration of dexamethasone results in less ED epinephrine use and may reflect dexamethasone's positive influence on the severity and short-term persistence of croup symptoms.
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Affiliation(s)
- Samina Ali
- Department of Pediatrics, Faculty of Medicine & Dentistry, University of Alberta, Edmonton, AB, Canada, .,Women and Children's Health Research Institute, Edmonton, AB, Canada,
| | - Aaron Moodley
- Department of Pediatrics, Faculty of Medicine, University of Saskatchewan, Saskatoon, SK, Canada
| | | | - Eddie Chang
- Department of Emergency Medicine, Faculty of Medicine & Dentistry, University of Alberta, Edmonton, AB, Canada
| | - Allison Kabaroff
- Department of Emergency Medicine, Faculty of Medicine & Dentistry, University of Alberta, Edmonton, AB, Canada
| | - Kevin Lobay
- Department of Emergency Medicine, Faculty of Medicine & Dentistry, University of Alberta, Edmonton, AB, Canada
| | - Dominic Allain
- Department of Pediatrics, Faculty of Medicine, Dalhousie University, Halifax, NS, Canada
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Gates A, Gates M, Vandermeer B, Johnson C, Hartling L, Johnson DW, Klassen TP. Glucocorticoids for croup in children. Cochrane Database Syst Rev 2018; 8:CD001955. [PMID: 30133690 PMCID: PMC6513469 DOI: 10.1002/14651858.cd001955.pub4] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
BACKGROUND Glucocorticoids are commonly used for croup in children. This is an update of a Cochrane Review published in 1999 and previously updated in 2004 and 2011. OBJECTIVES To examine the effects of glucocorticoids for the treatment of croup in children aged 0 to 18 years. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (the Cochrane Library, Issue 2, 2018), which includes the Cochrane Acute Respiratory Infections Group's Specialised Register, Ovid MEDLINE Epub Ahead of Print, In-Process & Other Non-Indexed Citations and Ovid MEDLINE (1946 to 3 April 2018), and Embase (Ovid) (1996 to 3 April 2018, week 14), and the trials registers ClinicalTrials.gov (3 April 2018) and the World Health Organization International Clinical Trials Registry Platform (ICTRP, 3 April 2018). We scanned the reference lists of relevant systematic reviews and of the included studies. SELECTION CRITERIA We included randomised controlled trials (RCTs) that investigated children aged 0 to 18 years with croup and measured the effects of glucocorticoids, alone or in combination, compared to placebo or another pharmacologic treatment. The studies needed to report at least one of our primary or secondary outcomes: change in croup score; return visits, (re)admissions or both; length of stay; patient improvement; use of additional treatments; and adverse events. DATA COLLECTION AND ANALYSIS One author extracted data from each study and another verified the extraction. We entered the data into Review Manager 5 for meta-analysis. Two review authors independently assessed risk of bias for each study using the Cochrane 'Risk of bias' tool and the certainty of the body of evidence for the primary outcomes using the GRADE approach. MAIN RESULTS We added five new RCTs with 330 children. This review now includes 43 RCTs with a total of 4565 children. We assessed most (98%) studies as at high or unclear risk of bias. Compared to placebo, glucocorticoids improved symptoms of croup at two hours (standardised mean difference (SMD) -0.65, 95% confidence interval (CI) -1.13 to -0.18; 7 RCTs; 426 children; moderate-certainty evidence), and the effect lasted for at least 24 hours (SMD -0.86, 95% CI -1.40 to -0.31; 8 RCTs; 351 children; low-certainty evidence). Compared to placebo, glucocorticoids reduced the rate of return visits or (re)admissions or both (risk ratio 0.52, 95% CI 0.36 to 0.75; 10 RCTs; 1679 children; moderate-certainty evidence). Glucocorticoid treatment reduced the length of stay in hospital by about 15 hours (mean difference -14.90, 95% CI -23.58 to -6.22; 8 RCTs; 476 children). Serious adverse events were infrequent. Publication bias was not evident. Uncertainty remains with regard to the optimal type, dose, and mode of administration of glucocorticoids for reducing croup symptoms in children. AUTHORS' CONCLUSIONS Glucocorticoids reduced symptoms of croup at two hours, shortened hospital stays, and reduced the rate of return visits to care. Our conclusions have changed, as the previous version of this review reported that glucocorticoids reduced symptoms of croup within six hours.
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Affiliation(s)
- Allison Gates
- University of AlbertaDepartment of Pediatrics and the Alberta Research Centre for Health EvidenceEdmontonAlbertaCanadaT6G 1C9
| | - Michelle Gates
- University of AlbertaDepartment of Pediatrics and the Alberta Research Centre for Health EvidenceEdmontonAlbertaCanadaT6G 1C9
| | - Ben Vandermeer
- University of AlbertaDepartment of Pediatrics and the Alberta Research Centre for Health EvidenceEdmontonAlbertaCanadaT6G 1C9
| | - Cydney Johnson
- University of AlbertaDepartment of Pediatrics and the Alberta Research Centre for Health EvidenceEdmontonAlbertaCanadaT6G 1C9
| | - Lisa Hartling
- University of AlbertaDepartment of Pediatrics and the Alberta Research Centre for Health EvidenceEdmontonAlbertaCanadaT6G 1C9
| | - David W Johnson
- Faculty of Medicine, University of Calgary, Alberta Children's HospitalDepartment of Pediatrics2888 Shaganappi Trail NWCalgaryABCanadaT3B 6A8
| | - Terry P Klassen
- Manitoba Institute of Child Health513‐715 McDermot AvenueWinnipegMBCanadaR3E 3P4
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Yang WC, Lee J, Chen CY, Chang YJ, Wu HP. Westley score and clinical factors in predicting the outcome of croup in the pediatric emergency department. Pediatr Pulmonol 2017; 52:1329-1334. [PMID: 28556543 DOI: 10.1002/ppul.23738] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2016] [Accepted: 04/26/2017] [Indexed: 11/07/2022]
Abstract
BACKGROUND Westley croup score has been generally used to assess the severity of croup. This study aimed to identify the individual factors associated with Westley score (WS) and other clinical factors in predicting the outcomes in the pediatric emergency department (PED). POPULATION AND METHOD We prospectively recruited patients with croup from the PED. The individual factors of WS, fever, age, and the length of hospital stay were analyzed to predict clinical outcomes. We calculated all the areas under the receiver operating characteristic (ROC) curve to determine the cutoff values of initial WS discriminating the need for admission to the wards. RESULT A total of 192 patients with croup were enrolled. Cyanosis and altered consciousness were not clinically significant even in patients with severe croup, whereas retraction and air entry were the major factors in WS for predicting clinical outcomes. The initial WS had a strong correlation with the length of hospital stay (r = 0.617, P < 0.001). ROC analysis showed that patients with an initial WS <2 (sensitivity, 5%; specificity, 100%; LR+ , 1.05; LR- , 0; AUC, 0.87) were discharged home while the patients with an initial WS ≥5 (sensitivity, 99%; specificity, 57%; LR+ , 41.0; LR- , 0.43) were more likely to require to stay in the PED. Patients with an WS ≥6 were more likely to be admitted to the wards (sensitivity, 97%; specificity, 47%; LR+ , 416.35; LR- , 0.54; AUC, 0.90) CONCLUSION: Patients with an initial WS of 1-2 could be safely treated at home and those with initial WS >5 required hospitalization for further treatment.
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Affiliation(s)
- Wen-Chieh Yang
- Department of Pediatric Emergency Medicine, Changhua Christian Children's Hospital, Changhua, Taiwan.,School of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Jung Lee
- Division of Pediatric General Medicine, Department of Pediatrics, Chang Gung Memorial Hospital, Taoyuan, Taiwan.,College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Chun-Yu Chen
- Department of Pediatric Emergency Medicine, Changhua Christian Children's Hospital, Changhua, Taiwan.,School of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Yu-Jun Chang
- Laboratory of Epidemiology and Biostastics, Changhua Christian Hospital, Changhua, Taiwan
| | - Han-Ping Wu
- Division of Pediatric General Medicine, Department of Pediatrics, Chang Gung Memorial Hospital, Taoyuan, Taiwan.,College of Medicine, Chang Gung University, Taoyuan, Taiwan
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Telephone Out Patient Score: The Derivation and Validation of a Telephone Follow-up Assessment Tool for Use in Clinical Research in Children With Croup. Pediatr Emerg Care 2016; 32:290-7. [PMID: 27139290 DOI: 10.1097/pec.0000000000000796] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE The objective was to derive a simple clinical scoring instrument for assessing children with croup by telephone for use in clinical research studies. METHODS We reviewed published literature on croup scores, surveyed experienced pediatric emergency nurses and physicians, and conducted a prospective cohort study. Score items were derived from published literature and surveys of experienced clinicians. We enrolled children with croup attending an urban pediatric emergency department. Families of children enrolled were contacted daily by telephone and asked standardized questions about their child's clinical symptoms and family functioning. Data from this survey were used to derive the clinical score. RESULTS We identified 11 unique croup scores from the literature and interviewed 6 experienced clinicians. We enrolled 330 children and achieved complete follow-up for 301. Of the various groupings of items and duration of assessment, the 2-item score (barky cough and stridor) was the simplest and most reliable. Three days of follow-up yielded optimal correlations. CONCLUSIONS We derived a 2-item Telephone Out Patient score assessed daily for 3 days after an emergency department visit. Validation of this score in a future, independent prospective cohort is needed.
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Isaiah A, Pereira KD, Correa AG. Tracheal Infections. INFECTIOUS DISEASES IN PEDIATRIC OTOLARYNGOLOGY 2016. [PMCID: PMC7153446 DOI: 10.1007/978-3-319-21744-4_12] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
Infectious processes of the trachea represent a distinct clinical entity with an evolving landscape owing to advances in airway management and vaccination practices. Untreated inflammatory processes of the trachea may present in the form of acute airway obstruction, potentially resulting in significant morbidity and even mortality. Therefore it is important to recognize the cardinal features of some of the common tracheal infectious processes to differentiate them from non-infectious pathology, as the latter is associated with a more indolent course. As with most other infectious processes of the airway, pathogens causing tracheal infection can be bacterial, viral or fungal in nature. Viral etiology represents the most common cause of laryngotracheal infection in a child. Bacterial infections of the trachea are responsible for more significant morbidity, including prolonged hospitalization, need for endotracheal intubation and even an occasional tracheostomy. The current chapter describes the clinical features and microbiology of tracheal infections at large, explores the utility of diagnostic tests, and provides an algorithm for management.
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Beigelman A, Chipps BE, Bacharier LB. Update on the utility of corticosteroids in acute pediatric respiratory disorders. Allergy Asthma Proc 2015; 36:332-8. [PMID: 26314814 DOI: 10.2500/aap.2015.36.3865] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND Corticosteroids, delivered systemically and by inhalation, are widely used for the treatment of multiple acute respiratory illnesses in children. However, the level of evidence to support the utility of this therapy varies between these different acute respiratory illnesses. OBJECTIVE To summarize the evidence regarding the utility of corticosteroids in the management of common acute pediatric respiratory conditions and to highlights the controversies regarding their use. METHODS Literature search of manuscripts describing the evidence regarding the efficacy of corticosteroids (systemic and inhaled) in the management of: acute asthma exacerbation among school age children, acute episodic wheeze among preschool children, viral croup, and acute viral bronchiolitis. RESULTS Current evidence indicates that systemic corticosteroids provide benefits for the treatment of acute asthma exacerbations in school age children, mainly in the acute care setting. In addition, high dose inhaled corticosteroid therapy administered in the Emergency Department appears to have comparable effect for the prevention of asthma-related hospital admission as systemic corticosteroids in this age group. In contrast, most available studies have not shown benefit for systemic corticosteroids during acute wheezing episodes in preschool children. Systemic corticosteroids decrease symptoms and the rate of hospital admissions in patients with severe croup; however, corticosteroids have no role in the treatment of acute bronchiolitis and their use in this condition should be discouraged. CONCLUSION Corticosteroids treatment response varies between the acute respiratory illnesses presented in this review. Future research should aim to fill the current gaps-of-knowledge regarding the utility this intervention such as the identification of specific wheezing phenotypes among preschool children which might benefit from systemic corticosteroids as a treatment for acute viral wheeze.
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Affiliation(s)
- Avraham Beigelman
- Division of Pediatric Allergy, Immunology, and Pulmonary Medicine, Washington University School of Medicine and St. Louis Children's Hospital, St. Louis, Missouri, USA
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Abstract
BACKGROUND Croup is a common childhood illness characterized by barky cough, stridor, hoarseness and respiratory distress. Children with severe croup are at risk for intubation. Nebulized epinephrine may prevent intubation. OBJECTIVES To assess the efficacy (measured by croup scores, rate of intubation and health care utilization such as rate of hospitalization) and safety (frequency and severity of side effects) of nebulized epinephrine versus placebo in children with croup, evaluated in an emergency department (ED) or hospital setting. SEARCH METHODS We searched CENTRAL 2013, Issue 6, MEDLINE (1966 to June week 3, 2013), EMBASE (1980 to July 2013), Web of Science (1974 to July 2013), CINAHL (1982 to July 2013) and Scopus (1996 to July 2013). SELECTION CRITERIA Randomized controlled trials (RCTs) or quasi-RCTs of children with croup evaluated in an ED or admitted to hospital. Comparisons were: nebulized epinephrine versus placebo, racemic nebulized epinephrine versus L-epinephrine (an isomer) and nebulized epinephrine delivered by intermittent positive pressure breathing (IPPB) versus nebulized epinephrine without IPPB. Primary outcome was change in croup score post-treatment. Secondary outcomes were rate and duration of intubation and hospitalization, croup return visit, parental anxiety and side effects. DATA COLLECTION AND ANALYSIS Two authors independently identified potentially relevant studies by title and abstract (when available) and examined relevant studies using a priori inclusion criteria, followed by methodological quality assessment. One author extracted data while the second checked accuracy. We use the standard methodological procedures expected by the Cochrane Collaboration. MAIN RESULTS Eight studies (225 participants) were included. In general, children included in the studies were young (average age less than two years in the majority of included studies). Severity of croup was described as moderate to severe in all included studies. Six studies took place in the inpatient setting, one in the ED and one setting was not specified. Six of the eight studies were deemed to have a low risk of bias and the risk of bias was unclear in the remaining two studies.Nebulized epinephrine was associated with croup score improvement 30 minutes post-treatment (three RCTs, standardized mean difference (SMD) -0.94; 95% confidence interval (CI) -1.37 to -0.51; I(2) statistic = 0%). This effect was not significant two and six hours post-treatment. Nebulized epinephrine was associated with significantly shorter hospital stay than placebo (one RCT, MD -32.0 hours; 95% CI -59.1 to -4.9). Comparing racemic and L-epinephrine, no difference in croup score was found after 30 minutes (SMD 0.33; 95% CI -0.42 to 1.08). After two hours, L-epinephrine showed significant reduction compared with racemic epinephrine (one RCT, SMD 0.87; 95% CI 0.09 to 1.65). There was no significant difference in croup score between administration of nebulized epinephrine via IPPB versus nebulization alone at 30 minutes (one RCT, SMD -0.14; 95% CI -1.24 to 0.95) or two hours (SMD -0.72; 95% CI -1.86 to 0.42). None of the studies sought or reported data on adverse effects. AUTHORS' CONCLUSIONS Nebulized epinephrine is associated with clinically and statistically significant transient reduction of symptoms of croup 30 minutes post-treatment. Evidence does not favor racemic epinephrine or L-epinephrine, or IPPB over simple nebulization.The authors note that data and analyses were limited by the small number of relevant studies and total number of participants and thus most outcomes contained data from very few or even single studies.
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Affiliation(s)
- Candice Bjornson
- Department of Pediatrics, Faculty of Medicine, University of Calgary, Alberta Children's Hospital, 2888 Shaganappi Trail NW, Calgary, Alberta, Canada, T3B 6A8
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Scott SD, Hartling L, O'Leary KA, Archibald M, Klassen TP. Stories – a novel approach to transfer complex health information to parents: A qualitative study. Arts Health 2012. [DOI: 10.1080/17533015.2012.656203] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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Dobrovoljac M, Geelhoed GC. How fast does oral dexamethasone work in mild to moderately severe croup? A randomized double-blinded clinical trial. Emerg Med Australas 2011; 24:79-85. [PMID: 22313564 DOI: 10.1111/j.1742-6723.2011.01475.x] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVE For children with croup controversy remains over dosage and time to onset of action of oral steroids. The Cochrane Collaboration and other reviews have suggested 0.6 mg/kg dexamethasone be used (despite some evidence that 0.15 mg/kg is effective) with no expectation of benefit before 4-6 h. This randomized double-blinded clinical trial examines whether 0.15 mg/kg dexamethasone works by 30 min. METHODS Children with croup aged above 6 months presenting to a tertiary paediatric ED with a Westley croup score of mild to moderate range (scores 1-6 out of 17) were randomized to receive either 0.15 mg/kg dexamethasone or oral placebo solution. Vital signs and croup score were recorded at study entry and every 10 min up to 1 h after administration of the study drug. The main outcome measure was croup score at 30 min. RESULTS Each group contained 35 children. Baseline characteristics were similar, except for respiratory rate, which was higher in the placebo group. There was a growing trend to a lower croup score in the dexamethasone group, evident from 10 min and statistically significant from 30 min. CONCLUSION For children with croup an oral dose of 0.15 mg/kg dexamethasone offers benefit by 30 min, much earlier than the 4 h suggested by the Cochrane Collaboration. This result might encourage doctors to treat more children with all severities of croup being less worried about potential side-effects and delayed benefit.
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Affiliation(s)
- Milana Dobrovoljac
- Emergency Department, Princess Margaret Hospital for Children, Perth, Western Australia, Australia
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Abstract
BACKGROUND Croup (laryngotracheobronchitis) is a common cause of upper airway obstruction in children with a peak incidence of 60 per 1000 child years in those aged between one and two years. It is characterised by hoarseness, a barking cough, and inspiratory stridor. These symptoms are thought to occur as a result of oedema of the larynx and trachea, which have been triggered by a recent viral infection. Para influenza virus type 1 is the agent most commonly identified in cases of croup. Severe cases are admitted to hospital and steroid treatment is established to reduce disease severity. Treatment with humidified air was previously widely used and is still commonly recommended as home treatment. OBJECTIVES To assess the efficacy of humidified air in the treatment of croup. SEARCH STRATEGY We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library Issue 4, 2005), MEDLINE (1966 to January 2006) and EMBASE (1990 to January 2006). SELECTION CRITERIA Randomised controlled trials (RCTs) involving children suffering from croup treated with humidified air. DATA COLLECTION AND ANALYSIS Two authors independently identified potentially relevant abstracts identified from the search and then assessed the full papers for inclusion and methodological quality. Outcome measures included mortality, ventilation, admission to hospital, re-contact with medical services, number of days off school and relief of symptoms; these were separately analysed for the week following treatment. Data extraction was performed by the two authors then entered by one and checked by the second author. Missing data were obtained from trial authors where possible. Data were analysed using Review Manager version 4.2. Sensitivity and sub-group analysis were not possible due to the paucity of trials. MAIN RESULTS Three studies in emergency settings provided data on 135 patients with moderate croup for the main outcome (croup score). The combined results from 20 to 60 minutes in the three studies marginally favoured the treatment group with a weighted standardised mean difference of -0.14 (95% confidence interval (CI) -0.75 to 0.47). No other outcomes were significantly different between the groups. AUTHORS' CONCLUSIONS The croup score of children managed in an emergency setting with mild to moderate croup probably does not improve greatly with inhalation of humidified air. Further research is needed in primary care settings, using a wider range of more sensitive outcome measures.
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Affiliation(s)
- Michael Moore
- Aldermoor Health CentrePrimary Care Research Network South WestAldermoor CloseSouthamptonUKSO16 5ST
| | - Paul Little
- University of Southampton School of MedicineDepartment of Community Clinical SciencesAldermoor Health CentreAldermoor CloseSouthamptonUKS016 5ST
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Bjornson C, Russell KF, Vandermeer B, Durec T, Klassen TP, Johnson DW. Nebulized epinephrine for croup in children. Cochrane Database Syst Rev 2011:CD006619. [PMID: 21328284 DOI: 10.1002/14651858.cd006619.pub2] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Croup is a common childhood illness characterized by barky cough, stridor, hoarseness and respiratory distress. Children with severe croup are at risk for intubation. Nebulized epinephrine (NE) may prevent intubation. OBJECTIVES To evaluate the efficacy and safety of NE in children presenting to emergency department (ED) or admitted to hospital with croup. SEARCH STRATEGY We searched CENTRAL (The Cochrane Library 2010, Issue 4), containing the Cochrane Acute Respiratory Infections Group's Specialized Register, MEDLINE (1966 to November Week 1, 2010), EMBASE (1980 to November 2010), Web of Science (1974 to November 2010), CINAHL (1982 to November 2010) and Scopus (1996 to November 2010). SELECTION CRITERIA Randomized controlled trials (RCTs) or quasi-RCTs of children with croup evaluated in an ED or admitted to hospital. Comparisons were: NE versus placebo, racemic NE versus L-epinephrine (an isomer), and NE delivered by intermittent positive pressure breathing (IPPB) versus NE without IPPB. Primary outcome was change in croup score post-treatment. Secondary outcomes were rate and duration of intubation and hospitalization, croup return visit, parental anxiety and side effects. DATA COLLECTION AND ANALYSIS Two authors independently identified potentially relevant studies by title and abstract (when available) and examined relevant studies using a priori inclusion criteria, followed by methodologic quality assessment. One author extracted data while the second checked accuracy. We performed standard statistical analyses. MAIN RESULTS Eight studies (225 participants) were included. NE was associated with croup score improvement 30 minutes post-treatment (three RCTs, standardized mean difference (SMD) -0.94; 95% confidence interval (CI) -1.37 to -0.51; I(2) statistic = 0%). This effect was not significant two and six hours post-treatment. NE was associated with significantly shorter hospital stay than placebo (one RCT, mean difference -32.0 hours; 95% CI -59.1 to -4.9). Comparing racemic and L-epinephrine, no difference in croup score was found after 30 minutes (SMD 0.33; 95% CI -0.42 to 1.08). After two hours, L-epinephrine showed significant reduction compared with racemic epinephrine (one RCT, SMD 0.87; 95% CI 0.09 to 1.65). There was no significant difference in croup score between administration of NE via IPPB versus nebulization alone at 30 minutes (one RCT, SMD -0.14; 95% CI -1.24 to 0.95) or two hours (SMD -0.72; 95% CI -1.86 to 0.42). AUTHORS' CONCLUSIONS NE is associated with clinically and statistically significant transient reduction of symptoms of croup 30 minutes post-treatment. Evidence does not favor racemic epinephrine or LE, or IPPB over simple nebulization.
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Affiliation(s)
- Candice Bjornson
- Department of Pediatrics, Faculty of Medicine, University of Calgary, Alberta Children's Hospital, 2888 Shaganappi Trail NW, Calgary, Alberta, Canada, T3B 6A8
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Abstract
BACKGROUND Since the initial publication of this systematic review in 1997, several randomized trials examining the benefit of glucocorticoids have been published. The objective of this review is to provide evidence to guide clinicians in their treatment of patients with croup by determining the effectiveness of glucocorticoids and to identify areas requiring future research. OBJECTIVES To determine the effect of glucocorticoids for children with croup. SEARCH STRATEGY We searched CENTRAL (2010, Issue 3), which contains the Cochrane Acute Respiratory Infections Group's Specialised Register, MEDLINE (1966 to July week 2, 2010) and EMBASE.com (1974 to July 2010). We also contacted authors of identified croup trials published in the last 10 years to inquire about additional published or unpublished trials. SELECTION CRITERIA Randomised controlled trials (RCTs) that examine children with croup and objectively measure the effectiveness of glucocorticoids. DATA COLLECTION AND ANALYSIS Two review authors identified studies for potential relevance based on the review of the title and abstract (when available). Two review authors independently reviewed studies for relevance using a priori inclusion criteria and assessed trial quality. Differences were resolved by consensus. One review author extracted data using a structured form and another review author checked the results for accuracy. We performed standard statistical analyses. MAIN RESULTS Thirty-eight studies were included (n = 4299). Glucocorticoids were associated with an improved Westley score (maximum 17 points) at six hours with a mean difference of -1.2 (95% confidence interval (CI) -1.6 to -0.8) and at 12 hours -1.9 (95% CI -2.4 to -1.3); at 24 hours this improvement was no longer significant (-1.3, 95% CI -2.7 to 0.2). Fewer return visits and/or (re)admissions occurred in participants treated with glucocorticoids (risk ratio (RR) 0.5; 95% CI 0.3 to 0.7). Length of time spent in accident and emergency or hospital (mean difference 12 hours, five to 19 hours) was significantly decreased for participants treated with glucocorticoids. Use of epinephrine decreased for children treated with a glucocorticoid (risk difference 10%; 95% CI 1 to 20). AUTHORS' CONCLUSIONS Dexamethasone and budesonide are effective in relieving the symptoms of croup as early as six hours after treatment. Fewer return visits and/or (re)admissions are required and the length of time spent in hospital is decreased. Research is required to examine the most beneficial method for disseminating croup practice guidelines and to increase the uptake of evidence.
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Affiliation(s)
- Kelly F Russell
- Department of Pediatrics, University of Alberta, Aberhart Centre One, 11402 University Ave, Edmonton, Alberta, Canada, T6G 2J3
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Hartling L, Scott S, Pandya R, Johnson D, Bishop T, Klassen TP. Storytelling as a communication tool for health consumers: development of an intervention for parents of children with croup. Stories to communicate health information. BMC Pediatr 2010; 10:64. [PMID: 20813044 PMCID: PMC2940891 DOI: 10.1186/1471-2431-10-64] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2010] [Accepted: 09/02/2010] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Stories may be an effective tool to communicate with and influence patients because of their ability to engage the reader. The objective of this paper is to describe the development of a story-based intervention for delivery of health evidence to parents of children with croup for use in a randomized controlled trial. METHODS A creative writer interviewed parents of children with croup presenting to the pediatric emergency department (ED) and drafted stories. We revised the stories based on written participant feedback and edited the stories to incorporate research evidence and health information. An illustrator and graphic designer developed story booklets which were evaluated through focus groups. RESULTS Ten participants provided feedback on the five stories drafted by the creative writer. Participants liked the concept but found the writing overly sophisticated and wanted more character development and more medical/health information. Participants highlighted specific story content that they liked and disliked. The revised stories were evaluated through focus groups involving eight individuals. Feedback was generally positive; one participant questioned the associated costs. Participants liked the graphics and layout; felt that they could identify with the stories; and felt that it was easier to get information compared to a standard medical information sheet. Participants provided feedback on the story content, errors and inconsistencies, and preferences of writing style and booklet format. Feedback on how to package the stories was provided by attendees at a national meeting of pediatric emergency researchers. CONCLUSIONS Several challenges arose during the development of the stories including: staying true to the story versus being evidence based; addressing the use of the internet by consumers as a source of health information; balancing the need to be comprehensive and widely applicable while being succinct; considerations such as story length, reading level, narrative mode, representation of different demographics and illness experiences, graphics and layout. The process was greatly informed by feedback from the end-user group. This allowed us to shape our products to ensure accuracy, credibility, and relevance. Our experience is valuable for further work in the area of stories and narratives, as well as more broadly for identifying and developing communication strategies for healthcare consumers.
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Affiliation(s)
- Lisa Hartling
- Alberta Research Centre for Health Evidence, Department of Pediatrics, University of Alberta, Edmonton, Canada.
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Dobrovoljac M, Geelhoed GC. 27 years of croup: an update highlighting the effectiveness of 0.15 mg/kg of dexamethasone. Emerg Med Australas 2009; 21:309-14. [PMID: 19682017 DOI: 10.1111/j.1742-6723.2009.01202.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To update an earlier observational study (1980-1995) documenting dramatic improvements in the management of croup with the mandatory use of a single oral dose of dexamethasone and to ascertain whether a reduction from a dose of 0.6 to 0.15 mg/kg in 1995 maintained these improved outcomes over the next 11 years. METHODS We evaluated retrospectively the experience of children with croup in Princess Margaret Hospital for Children, the only tertiary paediatric hospital in Western Australia, over the subsequent 11 year period from 1996 to 2006 inclusive. Data were updated from ED, general hospital and the intensive care unit records to show the numbers of children presenting to the hospital, admitted, transferred to intensive care and intubated. We also recorded the length of hospital stay and representation rate of all cases within 7 days. RESULTS The dramatic improvements in outcomes for croup, including reduced admission rates, length of stay, transfers to the intensive care unit, intensive care unit days and number of intubations as reported in our earlier paper, were maintained using 0.15 mg/kg dexamethasone. Admission rates for croup have fallen from 30% in the early 1990s to less than 15% in recent years, whereas the representation rate has risen slightly. CONCLUSION The improved outcomes for children with croup presenting to our paediatric ED have been maintained with a reduced, single oral dose of 0.15 mg/kg of dexamethasone.
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Affiliation(s)
- Milana Dobrovoljac
- Emergency Department, Princess Margaret Hospital for Children, Western Australia, Australia
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Sinha A, Jayashree M, Singhi S. Aerosolized L-epinephrine vs budesonide for post extubation stridor: a randomized controlled trial. Indian Pediatr 2009; 47:317-22. [PMID: 19736368 DOI: 10.1007/s13312-010-0060-z] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2008] [Accepted: 04/24/2009] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To compare the efficacy and adverse effects of aerosolized L-epinephrine vs budesonide in the treatment of post-extubation stridor. STUDY DESIGN Randomized controlled trial. SETTING Pediatric intensive care unit (PICU) of a tertiary teaching and referral hospital. SUBJECTS Sixty two patients with a stridor score ?4 following extubation. INTERVENTION Patients were randomized to receive either aerosolized L-epinephrine (n=32) or budesonide (n =30). Respiratory rate, heart rate, stridor score, blood pressure and oxygen saturation were recorded from 0 min to 24 hours. OUTCOME MEASURES Stridor score remaining at >4, need for renebulization and reintubation between 20 min to 24 hours were primary outcome measures. Tachycardia (HR > normal for age), hypertension (BP >95th centile for age) and hypoxia (SpO2 < 92% for 5 min) were secondary outcome measures. RESULTS Both drugs showed a significant and comparable decline in the median (95% CI) stridor scores from baseline to 60 min [4 (4.10-4.50) to 2.00 (1.46-2.67) for budesonide vs 4 (4.12-5.00) to 2.00 (1.31 -2.75) for epinephrine]. At 2 hours, the stridor scores were significantly lower in the epinephrine as compared to budesonide group [0.00 (0.69-1.81) vs 3.00(1.75-3.32); P =0.02)]. However, the proportion of patients with stridor score >4 at any time between 20 min to 24 hrs (53.3% vs 53.1%; P=0.99), need for renebulization (40% vs 43.8%; P=0.76) and reintubation (20% vs 25%, P=0.638), and adverse effects were similar in both groups. CONCLUSIONS Both aerosolized L-epinephrine and budesonide were equally effective in their initial therapeutic response in post-extubation stridor. However, epinephrine showed a more sustained effect.
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Affiliation(s)
- A Sinha
- Department of Pediatrics, Postgraduate Institute of Medical Education and Research, Chandigarh, India
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Abstract
Most children who present with acute onset of barky cough, stridor, and chest-wall indrawing have croup. A careful history and physical examination is the best method to confirm the diagnosis and to rule out potentially serious alternative disorders such as bacterial tracheitis and other rare causes of upper-airway obstruction. Epinephrine delivered via a nebuliser is effective for temporary relief of symptoms of airway obstruction. Corticosteroids are the mainstay of treatment, and benefit is seen in children with all levels of severity of croup, including mild cases.
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Affiliation(s)
- Candice L Bjornson
- Department of Paediatrics, Faculty of Medicine, University of Calgary, Calgary, AB, Canada
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Long SS. Respiratory Tract Symptom Complexes. PRINCIPLES AND PRACTICE OF PEDIATRIC INFECTIOUS DISEASE 2008. [PMCID: PMC7310934 DOI: 10.1016/b978-0-7020-3468-8.50029-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 12/03/2022]
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Abstract
In the 1960s, managing croup was simple - put the child in the bathroom and run a hot shower. In most cases, the child's symptoms would be controlled. When the mist from the shower failed to control the croup, the parents would take the child to an emergency room. Often, the child would get better on the way to the hospital, thanks to the cool, outside air. At the hospital, a 'croupette' would be available for some children, and the health care providers hoped that the children would remain quiet in the strange tent filled with cold mist. Some hospitals even had special croup rooms where steam was piped in, and the whole room was filled with cold mist. Needless to say, nursing staff were not eager to work in these rooms. The last resort of treatment was a tracheotomy because the art of intubation had not yet been mastered. Two randomized studies failed to show the benefit of cool mist, and, today, it is rarely used (1,2).
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Hartling L, Scott-Findlay S, Johnson D, Osmond M, Plint A, Grimshaw J, Klassen TP. Bridging the Gap between Clinical Research and Knowledge Translation in Pediatric Emergency Medicine. Acad Emerg Med 2007. [DOI: 10.1111/j.1553-2712.2007.tb02375.x] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Bjornson CL, Johnson DW. Croup in the paediatric emergency department. Paediatr Child Health 2007; 12:473-477. [PMID: 19030411 PMCID: PMC2528757 DOI: 10.1093/pch/12.6.473] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/07/2007] [Indexed: 11/12/2022] Open
Abstract
Croup is a common childhood illness. The majority of children presenting with an acute onset of barky cough, stridor and indrawing have croup. A careful history and physical examination is necessary to confirm the diagnosis of croup, and to rule out potentially serious alternative causes of upper airway obstruction. Nebulized adrenaline is effective for the temporary relief of airway obstruction. Corticosteroids are the mainstay of treatment in children with croup of all levels of severity.
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Affiliation(s)
- Candice L Bjornson
- Department of Paediatrics, Faculty of Medicine, University of Calgary, Edmonton, Alberta
| | - David W Johnson
- Department of Paediatrics, Faculty of Medicine, University of Calgary, Edmonton, Alberta
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Abstract
BACKGROUND Croup (laryngotracheobronchitis) is a common cause of upper airway obstruction in children with a peak incidence of 60 per 1000 child years in those aged between one and two years. It is characterised by hoarseness, a barking cough, and inspiratory stridor. These symptoms are thought to occur as a result of oedema of the larynx and trachea, which have been triggered by a recent viral infection. Para influenza virus type 1 is the agent most commonly identified in cases of croup. Severe cases are admitted to hospital and steroid treatment is established to reduce disease severity. Treatment with humidified air was previously widely used and is still commonly recommended as home treatment. OBJECTIVES To assess the efficacy of humidified air in the treatment of croup. SEARCH STRATEGY We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library Issue 4, 2005), MEDLINE (1966 to January 2006) and EMBASE (1990 to January 2006). SELECTION CRITERIA Randomised controlled trials (RCTs) involving children suffering from croup treated with humidified air. DATA COLLECTION AND ANALYSIS Two authors independently identified potentially relevant abstracts identified from the search and then assessed the full papers for inclusion and methodological quality. Outcome measures included mortality, ventilation, admission to hospital, re-contact with medical services, number of days off school and relief of symptoms; these were separately analysed for the week following treatment. Data extraction was performed by the two authors then entered by one and checked by the second author. Missing data were obtained from trails authors where possible. Data were analysed using Review Manager version 4.2. Sensitivity and sub-group analysis were not possible due to the paucity of trials. MAIN RESULTS Three studies in emergency settings provided data on 135 patients with moderate croup for the main outcome (croup score). The combined results from 20 to 60 minutes in the three studies marginally favoured the treatment group with a weighted standardised mean difference of -0.14 (95% confidence interval (CI) -0.75 to 0.47). No other outcomes were significantly different between the groups. AUTHORS' CONCLUSIONS The croup score of children managed in an emergency setting with mild to moderate croup probably does not improve greatly with inhalation of humidified air. Further research is needed in primary care settings, using a wider range of more sensitive outcome measures.
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Affiliation(s)
- M Moore
- Three Swans Surgery, Rollestone Street, Salisbury, UK SP1 1DX.
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Johnson DW, Craig W, Brant R, Mitton C, Svenson L, Klassen TP. A cluster randomized controlled trial comparing three methods of disseminating practice guidelines for children with croup [ISRCTN73394937]. Implement Sci 2006; 1:10. [PMID: 16722541 PMCID: PMC1471799 DOI: 10.1186/1748-5908-1-10] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2006] [Accepted: 04/28/2006] [Indexed: 11/10/2022] Open
Abstract
Background The optimal management of croup – a common respiratory illness in young children – is well established. In particular, treatment with corticosteroids has been shown to significantly reduce the rate and duration of intubation, hospitalization, and return to care for on-going croup symptoms. Furthermore treatment with a single dose of corticosteroids does not appear to result in any significant adverse outcomes, and yields overall cost-savings for both families and the health care system. However, as has been shown with many other diseases, there is a significant gap between what we know and what we do. The overall aim of this study is to identify, from a societal perspective, the costs and associated benefits of three strategies for implementing a practice guideline that addresses the management of croup. Methods/designs We propose to use a matched pair cluster trial in 24 Alberta hospitals randomized into three intervention groups. We will use mixed methods to assess outcomes including linkage and analysis of administrative databases obtained from Alberta Health and Wellness, retrospective medical chart audit, and prospective telephone surveys of the parents of children diagnosed to have croup. The intervention strategies to be compared will be mailing of printed educational materials (low intensity intervention), mailing plus a combination of interactive educational meetings, educational outreach visits, and reminders (intermediate intensity intervention), and a combination of mailing, interactive sessions, outreach visits, reminders plus identification of local opinion leaders and establishment of local consensus processes (high intensity intervention). The primary objective is to determine which of the three intervention strategies are most effective at lowering the rate of hospital days per 1,000 disease episodes. Secondary objectives are to determine which of the three dissemination strategies are most effective at increasing the use of therapies of known benefit. An economic analysis will be conducted to determine which of the three intervention strategies will most effectively reduce total societal costs including all health care costs, costs borne by the family, and costs stemming from the strategies for disseminating guidelines.
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Affiliation(s)
- David W Johnson
- Department of Pediatrics, Faculty of Medicine, University of Calgary, Calgary Alberta, Canada
| | - William Craig
- Department of Pediatrics, Faculty of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Rollin Brant
- Department of Statistics, University of British Columbia, Vancouver, British Columbia, Canada
| | - Craig Mitton
- Faculty of Health and Social Development, University of British Columbia- Okanagan, Kelowna, British Columbia, Canada
| | - Larry Svenson
- Health Surveillance, Alberta Health and Wellness, Edmonton, Alberta, Canada
| | - Terry P Klassen
- Department of Pediatrics, Faculty of Medicine, University of Alberta, Edmonton, Alberta, Canada
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Affiliation(s)
- Milton Tenenbein
- Department of Pediatrics, University of Manitoba, Children's Hospital, 840 Sherbrook St, Winnipeg, Manitoba, R3E 1S1, Canada.
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Segal AO, Crighton EJ, Moineddin R, Mamdani M, Upshur REG. Croup hospitalizations in Ontario: a 14-year time-series analysis. Pediatrics 2005; 116:51-5. [PMID: 15995030 DOI: 10.1542/peds.2004-1892] [Citation(s) in RCA: 83] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE Croup is the most common form of airway obstruction in children. Known to be primarily viral, the seasonality of croup has been examined largely through its association with the human parainfluenza viruses. This study examined the seasonal pattern of croup hospitalizations in relation to age and gender for the province of Ontario during a 14-year period. METHODS A retrospective, population-based study design was used to examine seasonal and temporal patterns of croup hospitalizations from April 1, 1988, to March 31, 2002. All residents of Ontario who were aged 0 to 4 years and eligible for universal health coverage during the study period were included for analysis. Time-series analyses then were conducted on monthly aggregations of hospitalizations. RESULTS This study found strong evidence of croup hospitalization seasonality, with a biennial midautumn peak and annual summer trough, evident throughout the 14-year study period (Fisher's kappa = 51.11; Bartlett Kolmogorov Smirnov = 0.552). The pattern was observed in all children aged 0 to 4, although boys were hospitalized 2 times more often than girls of the same age. Rates of croup hospitalization were lower for children aged 1 to 4 years than for children aged 0 to <1. A marked decrease in croup hospitalizations was observed after the winter of 1993/1994 and continued to decrease in a step-wise manner for the remainder of the study period. CONCLUSIONS This study delineates a clear biennial pattern of seasonal croup hospitalizations, varying by age and gender, with a large decrease in hospitalizations after the winter of 1993/1994. It is expected that these findings will have important implications for the treatment and management of childhood croup.
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Affiliation(s)
- Audrey O Segal
- Primary Care Research Unit, Sunnybrook and Women's College Health Sciences Centre, 2075 Bayview Ave, E-349, Toronto, ON, Canada M4N 3M5
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Abstract
OBJECTIVE To evaluate the effect of adding inhaled budesonide (2 mg) to oral dexamethasone 0.15 mg/kg in children hospitalized with croup. SETTING Observation ward of a Tertiary Paediatric Hospital Emergency Department. SUBJECTS Seventy-two children (age range 3 to 126 months) hospitalized with croup. INTERVENTION Children randomized to receive either 2 mg of nebulized budesonide or placebo, with all children receiving a single oral dose of 0.15 mg/kg dexamethasone. OUTCOME MEASURES Primary outcome was duration of hospital stay. Other measures included croup scores from 0 to 12 hours, use of nebulized epinephrine, duration of croup symptoms, duration of viral symptoms, and return to medical care for croup or for any other reason following discharge from hospital. RESULTS Baseline characteristics for the 2 groups were similar. There was no difference in time to discharge for the 2 groups or for other outcome measures with a risk ratio of 1.3 (95% confidence intervals of 0.82 and 2.1). CONCLUSIONS The addition of inhaled budesonide (2 mg) to oral dexamethasone (0.15 mg/kg) offers no advantage in the treatment of children hospitalized with croup.
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Bjornson CL, Klassen TP, Williamson J, Brant R, Mitton C, Plint A, Bulloch B, Evered L, Johnson DW. A randomized trial of a single dose of oral dexamethasone for mild croup. N Engl J Med 2004; 351:1306-13. [PMID: 15385657 DOI: 10.1056/nejmoa033534] [Citation(s) in RCA: 135] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND The benefits of dexamethasone treatment for moderate-to-severe croup are well established. However, most children with croup have mild symptoms, and it is unknown whether they would derive the same degree of benefit from dexamethasone treatment as children with more severe disease. METHODS We conducted a double-blind trial at four pediatric emergency departments in which 720 children with mild croup were randomly assigned to receive one oral dose of either dexamethasone (0.6 mg per kilogram of body weight) or placebo. The children had mild croup, as defined by a score of < or =2 on the croup scoring system of Westley et al. The primary outcome was a return to a medical care provider for croup within seven days after treatment. The secondary outcome was the presence of ongoing symptoms of croup on days 1, 2, and 3 after treatment. Other outcomes included economic costs, hours of sleep lost by the child, and stress on the part of the parent in relation to the child's illness. RESULTS Baseline clinical characteristics were similar in the two groups. Return to medical care was significantly lower in the dexamethasone group (7.3 percent vs. 15.3 percent, P<0.001). In the dexamethasone group, there was quicker resolution of croup symptoms (P=0.003), less lost sleep (P<0.001), and less stress on the part of the parent (P<0.001). CONCLUSIONS For children with mild croup, dexamethasone is an effective treatment that results in consistent and small but important clinical and economic benefits. Although the long-term effects of this treatment are not known, our data support the use of dexamethasone in most, if not all, children with croup.
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Cetinkaya F, Tüfekçi BS, Kutluk G. A comparison of nebulized budesonide, and intramuscular, and oral dexamethasone for treatment of croup. Int J Pediatr Otorhinolaryngol 2004; 68:453-6. [PMID: 15013613 DOI: 10.1016/j.ijporl.2003.11.017] [Citation(s) in RCA: 36] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2003] [Revised: 11/21/2003] [Accepted: 11/23/2003] [Indexed: 11/25/2022]
Abstract
OBJECTIVES Croup or acute laryngotracheobronchitis is the most common cause of the upper airway obstruction. Cool mist, nebulized racemic epinephrine and steroids are commonly used for therapy. Although steroid treatment can be applied orally, in nebulized form, or parenterally, no study has compared these three regimens yet. In this study, the efficacy of nebulized budesonide, and oral and intramuscular dexamethasone are compared for treatment of croup. STUDY DESIGN Sixty children aged 6-36 months were randomly allocated into four groups. The first three study groups (15 children in each) took nebulized budesonide, oral dexamethasone and intramuscular dexamethasone, respectively, in addition to salbutamol and other supportive measures and these were compared with the placebo group. All patients were evaluated with "Westley Croup Score" on admission to pediatric emergency department (0h) and at 24, 48 and 72h. RESULTS At the end of the study, the croup scores of all steroid treatment groups were significantly lower than the placebo group, but there was no statistical difference among them. CONCLUSIONS Nebulized budesonide, oral and parenteral dexamethasone have the same effectiveness for treatment of croup and the choice depends on conditions of the patient and the physician.
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Affiliation(s)
- Feyzullah Cetinkaya
- Pediatrician and Pediatric Allergist in Sisli Etfal Education and Research Hospital, Istanbul, Turkey
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Abstract
BACKGROUND Since the initial version of this systematic review in 1997, a number of randomised trials examining the benefit of glucocorticoids have been published, reflecting a continued interest in the use of glucocorticoids to treat patients with croup. The objective of this review was to provide evidence to guide clinicians in their treatment of patients with croup by determining the effectiveness of glucocorticoids and to identify areas of uncertainty for future research. OBJECTIVES To determine the effect of glucocorticoids for children with croup. SEARCH STRATEGY We searched The Cochrane Central Register of Controlled Trials (CENTRAL) (issue 1, 2003), MEDLINE (January 1966 to April 2003) and Excerpta Medica/EMBASE (January 1974 to August 2003). We also contacted authors of identified croup trials published in the last ten years to inquire about additional published or unpublished trials. SELECTION CRITERIA Randomised controlled trials that examine children with croup and objectively measure the effectiveness of glucocorticoid treatment. DATA COLLECTION AND ANALYSIS Based on review of the title and abstract (when available), two researchers identified studies for potential relevance. The complete text was retrieved and using a priori inclusion criteria, the studies were independently reviewed for relevance by two reviewers. Two observers independently assessed quality. Differences with respect to inclusion status and quality assessment were resolved by consensus. Data were extracted using a structured form by one reviewer and checked for accuracy by a second reviewer. Standard statistical analyses were performed. MAIN RESULTS Thirty-one studies were deemed relevant for inclusion (N = 3736). Glucocorticoid treatment was associated with an improvement in the Westley score at six hours with a weighted mean difference of -1.2 (95% confidence interval -1.6 to -0.8) and at 12 hours -1.9 (-2.4 to -1.3); at 24 hours this improvement was no longer significant (-1.3, -2.7 to 0.2). Fewer return visits and/or (re)admissions occurred in patients treated with glucocorticoids (relative risk 0.50; 0.36 to 0.70). Length of time spent in accident and emergency or hospital (weighted mean difference 12 hours, five to 19 hours) was significantly decreased for patients treated with glucocorticoids. Use of epinephrine decreased for children treated with a glucocorticoid (risk difference 10%; 1 to 20). No other decreases in additional treatments were found in the primary analysis. Publication bias does not impact results importantly. No between-trial significant differences were found between populations with mild and moderate croup. Oral dexamethasone may be superior to intramuscular dexamethasone. REVIEWER'S CONCLUSIONS Dexamethasone and budesonide are effective in relieving the symptoms of croup as early as six hours after treatment. Fewer return visits and/or (re)admissions are required and the length of time spent in hospital is decreased in inpatients. Dexamethasone is also effective in mild croup populations. Research is required to examine the most beneficial method for disseminating croup practice guidelines and to increase the uptake of evidence to improve outcomes.
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Ishimine P. A young boy with stridor. PEDIATRIC CASE REVIEWS (PRINT) 2003; 3:141-9. [PMID: 12865707 DOI: 10.1097/01.pca.0000074024.71816.3e] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- Paul Ishimine
- Children's Hospital and Health Center, San Diego, CA, USA
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&NA;. Corticosteroids first-line therapy in the treatment of croup. DRUGS & THERAPY PERSPECTIVES 2003. [DOI: 10.2165/00042310-200319040-00005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
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Affiliation(s)
- Paisal Lerdluedeeporn
- Division of Immunology/Allergy/Rheumatology, Mattel Children's Hospital at UCLA, UCLA Medical Center, Los Angeles, CA 90095, USA
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Abstract
Croup, or laryngotracheobronchitis, is a common childhood illness most often caused by viral infections. It is usually a benign, self-limiting disease, but can result in life-threatening upper airway obstruction. Until recently, it was not uncommon for children with severe croup to be admitted to intensive care for intubation. Management used to be limited to supportive measures, including mist therapy. The use of corticosteroids in patients with croup was controversial for many years but has, in the last decade, transformed the management of this disorder. Although corticosteroids do not alter the history of the viral infection, an adequate dose of oral or parenteral dexamethasone or nebulized budesonide has been shown to have a beneficial effect on the symptoms of croup.
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Affiliation(s)
- Wendy Stannard
- Department of Child Health, Institute of Lung Health, University of Leicester, Leicester, United Kingdom
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Abstract
Asthma therapy can be administered to children via a number of routes, including oral, inhaled (via a multiplicity of devices), rectal, intravenous, subcutaneous, and intramuscular. The inhaled route is used most often. This can reduce, but never eliminate, systemic absorption. Swallowed aerosolized medication is subject to hepatic first-pass metabolism, but this metabolic route is bypassed by the drug impacting on the airway, including the pharynx. Although there are a large number of studies from a laboratory setting about drug deposition characteristics, there is very little evidence from community-based studies about what families think actually works well in the everyday treatment of the child. However, it is clear that altering the inhaler device can result in marked changes in the dose administered, and any such change should be part of a review of the dose of prescribed medication. Nebulizers are being used much less frequently, and in particular, all but the most severe exacerbations can be treated at least as effectively with equivalent dosages of beta(2)-adrenoceptor agonists from a large volume spacer.
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Affiliation(s)
- Elizabeth Biggart
- Department of Paediatric Respiratory Medicine, Royal Brompton Hospital, Sydney Street, London SW3 6NP, United Kingdom
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Wright RB, Pomerantz WJ, Luria JW. New approaches to respiratory infections in children. Bronchiolitis and croup. Emerg Med Clin North Am 2002; 20:93-114. [PMID: 11826639 DOI: 10.1016/s0733-8627(03)00053-1] [Citation(s) in RCA: 35] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Croup is a disease that is commonly seen in children younger than the age of 6 years. The cause is viral, with parainfluenza viruses and RSV being the two most common pathogens. Treatment consists primarily of supportive care, and parents usually have tried humidification and cool air exposure before the child presents to the ED. Children with moderate to severe croup are usually seen in the ED. The use of steroids in an oral preparation results in a clinical improvement of outpatients with mild to moderate croup and reduces the need for hospitalization. The dosage range for oral dexamethasone is 0.15 mg/kg to 0.6 mg/kg. Nebulized budesonide may also be used. Racemic or L-epinephrine, both of which are equally effective, can be used for symptomatic treatment in severe croup. After administration of racemic or L-epinephrine, hospitalization is not automatic and patients can be discharged safely from the ED after a 3-hour of observation period. There should be no respiratory distress, and the patient should have access to follow-up and emergency care if needed.
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Affiliation(s)
- Robert Bruce Wright
- Division of Emergency Medicine, Children's Hospital Medical Center, Cincinnati, Ohio, USA.
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Schuh S, Coates AL, Binnie R, Allin T, Goia C, Corey M, Dick PT. Efficacy of oral dexamethasone in outpatients with acute bronchiolitis. J Pediatr 2002; 140:27-32. [PMID: 11815760 DOI: 10.1067/mpd.2002.120271] [Citation(s) in RCA: 104] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
OBJECTIVE To examine the efficacy of oral dexamethasone in acute bronchiolitis. STUDY DESIGN A double-blind randomized, placebo-controlled trial involving 70 children < 24 months old in the emergency department with Respiratory Disease Assessment Instrument > or = 6. Each patient received either 1 dose of 1 mg/kg of oral dexamethasone or placebo and was assessed hourly for a 4-hour period. Repeated measures regression analysis evaluated a change in the Respiratory Assessment Change Score (RACS). RESULTS The 2 groups had similar baseline characteristics with Respiratory Disease Assessment Inventory of 9.4 +/- 2.3 in the dexamethasone group (n = 36) and 10.0 +/- 2.7 in the placebo group (n = 34). The RACS was -5.0 +/- 3.1 in the dexamethasone group and -3.2 +/- 3.7 in the placebo group (P =.029). Poor RACS occurred in 41% and 17% of the placebo and dexamethasone groups, respectively (P =.034). Of the children treated with dexamethasone, 19% were hospitalized compared with 44% in the placebo group (P =.039). There was no difference in RACS between the groups on day 7 (P =.75). CONCLUSION Outpatients with moderate-to-severe acute bronchiolitis derive significant clinical and hospitalization benefit from oral dexamethasone treatment in the initial 4 hours of therapy.
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Affiliation(s)
- Suzanne Schuh
- Divisions of Emergency, Respiratory Medicine, and Paediatric Medicine, the Paediatric Outcomes Research Team and Research Institute, The Hospital for Sick Children, and the Department of Pediatrics, University of Toronto, Ontario, Canada
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Marchessault V. Historical review of croup. Paediatr Child Health 2001; 6:721-3. [DOI: 10.1093/pch/6.10.721] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Cada DJ, Levien T, Baker DE. Budesonide Inhalation Suspension. Hosp Pharm 2001. [DOI: 10.1177/001857870103600206] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Each month, subscribers to The Formulary® Monograph Service receive five to six researched monographs on drugs that are newly released or are in late Phase III trials. The monographs are targeted to your Pharmacy and Therapeutics Committee. Subscribers also receive monthly one-page summary monographs on the agents that are useful for agendas and pharmacy/nursing in-services. A comprehensive target drug utilization evaluation (DUE) is also provided each month. The monographs are published in printed form and on diskettes that allow customization. Subscribers to the The Formulary Monograph Service also receive access to a pharmacy bulletin board called The Formulary Information Exchange (The F.I.X). All topics pertinent to clinical pharmacy are discussed on The F.I.X. Through the cooperation of The Formulary, Hospital Pharmacy publishes selected reviews in this column. If you would like information about The Formulary Monograph Service or The F.I.X., call The Formulary at 800-322-4349. The February 2001 Formulary monographs are iron sucrose injection, oxybate sodium, diclofenac sodium gel, tacrolimus ointment, and docosanol. The DUE is on iron sucrose injection.
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Affiliation(s)
- Dennis J. Cada
- The Formulary; 601 West First Avenue, Spokane, WA 99201-3899
| | - Terri Levien
- Drug Information Pharmacist, Drug Information Center, Washington State University at Spokane; 601 West First Avenue, Spokane, WA 99201-3899
| | - Danial E. Baker
- Drug Information Center and College of Pharmacy, Washington State University at Spokane, 601 West First Avenue, Spokane, WA 99201-3899
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Hvizdos KM, Jarvis B. Budesonide inhalation suspension: a review of its use in infants, children and adults with inflammatory respiratory disorders. Drugs 2000; 60:1141-78. [PMID: 11129126 DOI: 10.2165/00003495-200060050-00010] [Citation(s) in RCA: 54] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
Budesonide, a topically active corticosteroid, has a broad spectrum of clinically significant local anti-inflammatory effects in patients with inflammatory lung diseases including persistent asthma. In infants and young children with persistent asthma, day- and night-time symptom scores, and the number of days in which beta2-agonist bronchodilators were required, were significantly lower during randomised, double-blind treatment with budesonide inhalation suspension 0.5 to 2 mg/day than placebo in 3 multicentre trials. Significantly fewer children discontinued therapy with budesonide inhalation suspension than with placebo because of worsening asthma symptoms in a study that included children who were receiving inhaled corticosteroids at baseline. Recent evidence indicates that budesonide inhalation suspension is significantly more effective than nebulised sodium cromoglycate in improving control of asthma in young children with persistent asthma. At a dosage of 2 mg/day, budesonide inhalation suspension significantly reduced the number of asthma exacerbations and requirements for systemic corticosteroids in preschool children with severe persistent asthma. In children with acute asthma or wheezing, the preparation was as effective as, or more effective than oral prednisolone in improving symptoms. In children with croup, single 2 or 4mg dosages of budesonide inhalation suspension were significantly more effective than placebo and as effective as oral dexamethasone 0.6 mg/kg or nebulised L-epinephrine (adrenaline) 4mg in alleviating croup symptoms and preventing or reducing the duration of hospitalisation. Early initiation of therapy with budesonide inhalation suspension 1 mg/day appears to reduce the need for mechanical ventilation and decrease overall corticosteroid usage in preterm very low birthweight infants at risk for chronic lung disease. In adults with persistent asthma, budesonide inhalation suspension < or =8 mg/day has been compared with inhaled budesonide 1.6 mg/day and fluticasone propionate 2 mg/day administered by metered dose inhaler. Greater improvements in asthma control occurred in patients during treatment with budesonide inhalation suspension than with budesonide via metered dose inhaler, whereas fluticasone propionate produced greater increases in morning peak expiratory flow rates than nebulised budesonide. Several small studies suggest that the preparation has an oral corticosteroid-sparing effect in adults with persistent asthma and that it may be as effective as oral corticosteroids during acute exacerbations of asthma or chronic obstructive pulmonary disease. The frequency of adverse events was similar in children receiving budesonide inhalation suspension 0.25 to 2 mg/day or placebo in 12-week studies. During treatment with budesonide inhalation suspension 0.5 to 1 mg/day in 3 nonblind 52-week studies, growth velocity in children was generally unaffected; however, a small but statistically significant decrease in growth velocity was detected in children who were not using inhaled corticosteroids prior to the introduction of budesonide inhalation suspension. Hypothalamic-pituitary-adrenal axis function was not affected by short (12 weeks) or long (52 weeks) term treatment with nebulised budesonide. In conclusion, budesonide inhalation suspension is the most widely available nebulised corticosteroid, and in the US is the only inhaled corticosteroid indicated in children aged > or =1 year with persistent asthma. The preparation is suitable for use in infants, children and adults with persistent asthma and in infants and children with croup.
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Affiliation(s)
- K M Hvizdos
- Adis International Limited, Auckland, New Zealand.
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Marguet C, Feray D, Bocquel N, Couderc L, Mallet E. [Respiratory distress in pediatric admission and emergency services. Epidemiology and evaluation criteria]. Arch Pediatr 2000; 7 Suppl 1:4S-9S. [PMID: 10793940 DOI: 10.1016/s0929-693x(00)88811-9] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
The medical part of the activity in the emergency units increased and has been ascribed to the raised number of infants or children admitted for acute dyspnea. This review is based on the published reports and the experience from the paediatric emergency unit from the Rouen area with 450,000 inhabitants, in France. We put forward the known epidemiological data and discussed the available means for the practitioner, which could help him in the decision to hospitalize. This review suggests that algorithms of treatment and severity evaluations must be set up in paediatric emergency units in order to validate them and specify the children who requires hospitalisation.
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Affiliation(s)
- C Marguet
- Unité des maladies respiratoires de l'enfant, hôpital Charles-Nicolle, centre hospitalo-universitaire de Rouen, France
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Abstract
BACKGROUND Since the last meta-analysis in 1989, a number of randomised trials on the benefit of glucocorticoids have been published, resulting in an increasing interest in the use of glucocorticoids to treat outpatients with croup. The objective of this review was to provide evidence to guide clinicians in their treatment of patients with croup, to examine the effectiveness of glucocorticoids in these patients, and to identify areas of uncertainty for future research. OBJECTIVES To determine the effect of glucocorticoids for children with croup. SEARCH STRATEGY We searched The Cochrane Controlled Trials Register, MEDLINE (January 1966 to August 1997) and Excerpta Medica/EMBASE (January 1974 to August 1997). We also contacted (by mail) authors of identified croup trials published in the last five years to inquire about other trials, published or unpublished. SELECTION CRITERIA Meta-analysis of randomised controlled trials that examine the effectiveness of glucocorticoid treatment in children with croup. DATA COLLECTION AND ANALYSIS Data were extracted using a structured form, which captured patient status (inpatient or outpatient), intervention and control, with the name of the drug, route of administration and dose. Data were also collected on the primary outcome measures comprised of a clinical croup score at baseline (as well as any other subsequent assessment times), length of stay (hours), patients status improved (yes/no), and use of co-interventions. The quality of the trials was assessed using empirically derived items that involved scales and components. Two researchers (TPK, MA) then selected studies as being potentially relevant based on a review of the titles and abstracts, if available. The complete text of these studies was then retrieved. All studies that had been retrieved were reviewed independently by two reviewers (AS, TPK). Data were extracted by one reviewer (MA) and checked for accuracy by a second reviewer (TPK). Two observers independently assessed quality (MA, JK), and inter rater agreement was measured by the intra class correlation. Differences were resolved by consensus. MAIN RESULTS Twenty-four studies were deemed relevant for inclusion (N=2221). Glucocorticoid treatment was associated with an improvement in the croup severity score at 6 hours with an effect size of -1.0 (95% confidence interval -1.5 to -0.6) and at 12 hours -1.0 (-1.6 to -0. 4); at 24 hours this improvement was no longer significant (-1.0, -2. 0 to 0.1). There was a decrease in the number of adrenaline treatments needed in children treated with glucocorticoids: a decrease of 9% (95% confidence interval 2 to 16%) among those treated with budesonide and of 12% (4 to 20%) among those treated with dexamethasone. There was also a decrease in the length of time spent in accident and emergency (-11 hours, 95% confidence interval -18 to 4 hours), and for inpatients hospital stay was reduced by 16 hours (-31 to 1 hour). Publication bias seems to play a part in these results. REVIEWER'S CONCLUSIONS Dexamethasone and budesonide are effective in relieving the symptoms of croup as early as 6 hours after treatment. Fewer co-interventions are used and the length of time spent in hospital is decreased in patients treated with glucocorticoids.
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Affiliation(s)
- M Ausejo
- Department of Pediatrics, University of Alberta, 2C3.67 Walter C. Mackenzie, Health Sciences Centre, Edmonton, Alberta, Canada, T6G 2R7.
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Klassen TP. Effectiveness of glucocorticoids in treating croup. Authors acknowledge Cochrane Collaboration. BMJ (CLINICAL RESEARCH ED.) 1999; 319:1577. [PMID: 10591737 PMCID: PMC1117282 DOI: 10.1136/bmj.319.7224.1577a] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Abstract
In the past decade, much progress has been made in the management of patients with croup. Where glucocorticoids have been adopted into practice, evidence shows that a decrease of health-care-service use is occurring in terms of fewer admissions to intensive care units and hospitals. The evidence may be summarized as follows. All children with croup symptoms who demonstrate increased work of breathing in the clinics or emergency departments should be treated with glucocorticoids. This treatment may be with nebulized budesonide (2 mg) or PO or IM dexamethasone (dose may be 0.15-0.6 mg/kg). Oral dexamethasone may be the best option because of its ease of administration, widespread availability, and lower cost. L-Epinephrine (5 mL of 1:1000) or racemic epinephrine (0.5 mL) should be considered for children with croup who have moderate or severe distress. No evidence supports the effectiveness of mist therapy, and physicians are in need of a randomized, controlled trial for this.
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Affiliation(s)
- T P Klassen
- Department of Pediatrics, University of Alberta, Edmonton, Canada
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