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Estimates of the annual incidence of croup in children under the age of 6 years range from 1.5–6%. Many are not admitted to hospital. Although for the great majority the illness is self-limiting without any medical intervention, symptoms may persist for days and very occasionally action is required to secure the airway.
An updated Cochrane systematic review1 published in January 2004 summarises the evidence from randomised controlled trials for the effectiveness of glucocorticoids in croup. There are two other systematic review protocols registered with the Cochrane Collaboration, on the use of nebulised epinephrine (adrenaline) and humidified air, which have not yet been published.
The first randomised controlled trial of steroids for croup was published in 1964.2 By 1989 a formal review of the evidence from the controlled trials then published had concluded “this meta-analysis supports the practice of using steroids to treat patients ill enough to be hospitalised for croup”.3 By 2003, when the literature search supporting the latest Cochrane review took place, a large number of randomised controlled trials of glucocorticoids in children with croup had been published. Most of these involved small numbers of children. This review summarises the findings of the Cochrane update in order to allow paediatricians to reach an informed judgement on prescribing.
The Cochrane review identified 31 unique studies with 51 comparisons. Seventeen trials were conducted on inpatients, and 14 on outpatients or emergency department attenders. Twenty-four studies (27 comparisons) involving 2878 children compared a glucocorticoid with placebo. The glucocorticoids studied included dexamethasone orally (12 comparisons, 5 placebo controlled), intramuscularly (16 comparisons, 9 placebo controlled), subcutaneously (2 placebo controlled comparisons), and via a nebuliser (3 comparisons, 2 placebo controlled); inhaled budesonide (11 comparisons, 6 placebo controlled); methylprednisolone (2 placebo controlled comparisons); and fluticasone (1 placebo controlled comparison). One study made two …