Croup in children

There is clear evidence that corticosteroids benefit children with symptoms of croup that range from mild to severe.32-34 In a meta-analysis of data from 10 clinical trials that included children with severe croup who required intensive care, corticosteroid treatment decreased endotracheal intubation by fivefold (odds ratio [OR] 0.21, 95% confidence interval [CI] 0.05 to 0.84).33A randomized clinical trial found that, in children admitted to hospital, corticosteroid treatment reduced length of hospital stay by one-third compared with placebo (duration of hospital stay: 12 h for dexamethasone and 13 h for budesonide v. 20 h for placebo, p < 0.03).35 In children who presented to emergency departments with moderate to severe croup included in a randomized clinical trial, cortico - steroid treatment reduced admission rates by half compared with placebo (35% v. 67%, p < 0.001).36 A randomized placebo-controlled trial included 720 children with mild croup seen in an emer- gency department and showed that corticosteroid treatment reduced return medical visits by half (7% v. 15%, p < 0.001), resulted in less stress and loss of sleep by parents, and reduced overall health care costs.37Whereas cortico ster oids appear to start reducing respiratory distress within an hour of oral administration,38,39 the drug effect continues to increase for at least 10 hours after administration.36 The reduction in the rate of use of health services, such as hospital admissions, is not significant until 3-6 hours after administration of corti co ster oids, which supports an observation period of that length before the decision is made whether to admit a child to hospital.36 The route of administration of corticosteroid (oral, nebulized or intramuscular injection) has received extensive study. Three randomized clinical trials comparing nebulized budesonide with either oral or intramuscular dexamethasone did not find a difference in duration of hospital stay (13 h for budesonide v. 12 h for intramuscular dexamethasone, nonsignificant),35 rate of admission to hospital (35% for budesonide v. 17% for intramuscular dexamethasone, p = 0.18)36 or clinical croup score at 4 hours (p = 0.70).44 Three randomized clinical trials have shown that intramuscular dexamethasone does not provide benefit over oral corticosteroid in either change in clinical croup score at 4 hours (p = 0.18),45 resolution of croup symptoms at 24 hours (2% for intramuscular v. 8% for oral administration, nonsignificant)46