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Croup - Management
Basis for recommendation

  • There is good evidence from a Cochrane systematic review that corticosteroids are beneficial in children with mild, moderate, and severe croup.
  • Oral administration of dexamethasone is preferred, as there is evidence that it is at least as effective as intramuscular dexamethasone or nebulized budesonide, and oral administration is less traumatic for the child. Although there are no published trials comparing single- and multiple-dose regimens of dexamethasone in croup, the short history of the disease suggests that a single dose should be sufficient [Bjornson and Johnson, 2008].
  • There is conflicting evidence regarding whether prednisolone is as effective as dexamethasone. Oral dexamethasone may reduce the need for additional medical attention compared to prednisolone. Expert reviewers suggested a repeat dose of prednisolone the following day particularly if there are any residual symptoms of stridor.
  • CKS has recommended the use of the lower dose (0.15 mg per kg) of dexamethasone. A dose of 0.6 mg per kg has been used traditionally and there is more evidence for the use of this dose (e.g. 12 of the 31 trials [n = 2032] in a Cochrane review used this dose [Russell et al, 2004]). However evidence from four randomized controlled trials showed no difference in primary outcome measures between doses of 0.15 mg per kg body weight, and 0.6 mg per kg body weight. Advice from the British National Formulary (BNF) and expert opinion is that a dose of 0.15 mg per kg body weight is sufficient. The BNF recommends using a dose of 0.15 mg per kg in children with mild croup and also giving this dose to children who are being admitted to hospital [BNF 55, 2008].
  • If prednisolone is used the BNF recommends a dose of 1–2 mg per kg body weight [BNF 55, 2008].
  • Although steroid treatment of children with croup is generally well tolerated, concerns exist about possible adverse events. There are limited data on harms because of the small sample size in all available studies [Cherry, 2005], but no adverse effects have been associated with the use of corticosteroids in children with croup [Bjornson and Johnson, 2008].

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