Cochrane for Clinicians

Putting Evidence into Practice

Glucocorticoids for Treatment of Croup

MICHAEL SCHOOFF, M.D., Clarkson Family Medicine Residency Program, Omaha, Nebraska

The Cochrane Abstract below is a summary of a review from the Cochrane Library. It is accompanied by an interpretation that will help clinicians put evidence into practice. Michael Schooff, M.D., presents a clinical scenario and question based on the Cochrane Abstract, along with the evidence-based answer and a full critique of the abstract.

Clinical Scenario

A two-year-old child presents with a barking cough, stridor, and tachypnea.

Clinical Question

Are glucocorticoids effective in treating children with croup?

Evidence-Based Answer

Compared with placebo, treatment with glucocorticoids results in reduced symptoms, less need for treatment with racemic epinephrine, fewer readmissions to emergency departments, and shorter hospital stays.

Cochrane Abstract Background. Since the initial version of this review in 1997, a number of randomized 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 review1 was to provide evidence to guide physicians 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 in children with croup. Search Strategy. The authors 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). They also contacted authors of identified croup trials published in the past 10 years to inquire about additional published or unpublished trials. Selection Criteria. Randomized controlled trials that examined children with croup and objectively measured the effectiveness of glucocorticoid treatment were included. Data Collection and Analysis. Based on reviews of titles and abstracts (when available), two researchers identified potentially relevant studies. The complete text was retrieved, and studies were independently reviewed for relevance by two reviewers using a priori inclusion criteria. Two observers independently assessed quality. Differences in 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. Primary Results. A total of 31 studies were deemed relevant for inclusion (N = 3,736). Glucocorticoid treatment was associated with an improvement in the Westley score at six hours (weighted mean difference [WMD], -1.2; 95 percent confidence interval [CI], -1.6 to -0.8) and at 12 hours (WMD, -1.9; 95 percent CI, -2.4 to -1.3); at 24 hours the improvement was no longer significant (WMD, -1.3; 95 percent CI, -2.7 to 0.2). Fewer return visits and readmissions occurred in patients treated with glucocorticoids (relative risk, 0.50; 95 percent CI, 0.36 to 0.70). The length of time spent in emergency departments and hospitals was significantly decreased in patients treated with glucocorticoids (WMD, 12 hours; 95 percent CI, five to 19 hours). Children treated with a glucocorticoid used less epinephrine (risk difference, 10 percent; 95 percent CI, 1 to 20 percent). No other decreases in additional treatments were found in the primary analysis. Publication bias does not significantly impact results. No between-trial significant differences were found between populations with mild and moderate croup. Oral dexamethasone may be superior to intramuscular dexamethasone. Reviewers' Conclusions. Dexamethasone and budesonide are effective in relieving the symptoms of croup as early as six hours after treatment. Fewer return visits and readmissions are required, and the length of time spent in the hospital is decreased in inpatients. Dexamethasone also is effective in patients with mild croup. Research is required to examine the most beneficial method for disseminating croup practice guidelines and to increase the uptake of evidence to improve outcomes. These summaries have been derived from Cochrane reviews published in the Cochrane Database of Systematic Reviews in the Cochrane Library. Their content has, as far as possible, been checked with the authors of the original reviews, but the summaries should not be regarded as an official product of the Cochrane Collaboration; minor editing changes have been made to the text (www.cochrane.org).

Practice Pointers

Croup is an acute viral inflammation of the upper and lower respiratory tracts, characterized by inspiratory stridor, barking cough, subglottic swelling, and respiratory distress. Each year, croup occurs in up to 6 percent of children six months to six years of age. Croup is self-limited, usually lasting four to seven days, but about one in 20 children with croup who present to emergency departments requires hospitalization.2

Standard therapy for croup includes cool-mist humidification, hydration, supplemental oxygen, and general comfort measures. Nebulized racemic epinephrine improves symptoms and reduces respiratory fatigue, but these results are transient. Hospitalization is indicated in children with increasing or persistent respiratory distress, fatigue, cyanosis, or dehydration. In severe cases, patients may require intubation and mechanical ventilation. Stridor, cyanosis, sternal retraction, tachypnea, and tachycardia increase the risk for intubation.3

Most of the articles evaluated in this review used the Westley croup scoring system4 to measure symptoms. This system assigns points for stridor, retractions, air entry, cyanosis, and level of consciousness. The use of glucocorticoids reduced symptom scores at six and 12 hours compared with placebo. In patients who received glucocorticoids, 69 percent improved at six hours, and 84 percent improved at 12 hours, compared with 46 percent and 61 percent, respectively, in patients who received placebo (number needed to treat [NNT], six to seven for both time intervals). Administration of glucocorticoids also led to fewer admissions or readmissions (NNT, 11), shorter emergency department and inpatient lengths of stay, and less need for racemic epinephrine.

There is insufficient research comparing the various glucocorticoids, or establishing the most effective glucocorticoid dosage and the most effective route of administration. Preliminary evidence suggests that oral and intramuscular dexamethasone may have equivalent efficacies, and that either may be more effective than nebulized dexamethasone or budesonide.5-7

This clinical content conforms to AAFP criteria for evidence-based continuing medical education (EB CME). EB CME is clinical content presented with practice recommendations supported by evidence that has been systematically reviewed by an AAFP-approved source. The practice recommendations in this activity are available online at http://www.cochrane.org/cochrane/revabstr/AB001955.htm.

The Author

MICHAEL SCHOOFF, M.D., is associate director of the Clarkson Family Medicine Residency Program in Omaha. He received his medical degree from the Uniformed Services University of the Health Sciences, F. Edward Hébert School of Medicine, Bethesda, Md., and completed a family practice residency at Womack Army Medical Center, Fort Bragg, N.C.

Address correspondence to Michael Schooff, M.D., Clarkson Family Medicine, 4200 Douglas St., Omaha, NE 68131 (e-mail: mschooff@nebraskamed.org). Reprints are not available from the author.

REFERENCES

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Cochrane Briefs

Antidepressants and Smoking Cessation

Clinical Question

Which antidepressants help patients stop smoking?

Evidence-Based Answer

Bupropion and nortriptyline increase the likelihood of smoking cessation, but selective serotonin reuptake inhibitors (SSRIs) do not.

Practice Pointers

The U.S. Preventive Services Task Force1 and U.S. Department of Health and Human Services2 recommend that physicians screen all adults for tobacco use and recommend intervention for those who report using tobacco products. There is good evidence that brief behavioral counseling and pharmacotherapy increase rates of abstinence. More intensive counseling has a dose-response relationship, with more minutes of contact producing better results. Nicotine replacement and bupropion have been approved by the U.S. Food and Drug Administration for use in smoking cessation.

Hughes and colleagues reviewed the literature to see if other antidepressants also improve rates of smoking cessation. All trials had at least six months of follow-up. Although nortriptyline and bupropion had the most studies meeting the inclusion criteria, there were also trials on sertraline, venlafaxine, and fluoxetine. Patients taking bupropion (19.3 versus 10.2 percent; pooled odds ratio [OR], 2.0; 95 percent confidence interval [CI], 1.7 to 2.3) or nortriptyline (18.5 versus 7.6 percent; pooled OR, 2.8; 95 percent CI, 1.8 to 4.3) had long-term abstinence rates higher than in those taking placebo. One small trial comparing bupropion with nortriptyline did not show a statistically significant difference. In five studies of SSRIs (largely fluoxetine) with 1,521 patients, there was no significant difference between treated patients and control patients in rates of long-term abstinence. This systematic review did not address the question of whether combining pharmaceutical and counseling interventions produces higher quit rates. However, patients who report using tobacco should receive at least a brief counseling intervention and an offer of medication.

CLARISSA KRIPKE, M.D.

Hughes JR, et al. Antidepressants for smoking cessation. Cochrane Database Syst Rev 2004;(3):CD000031.

REFERENCE

Hormonal Contraceptives and Weight Gain

Clinical Question

Do combination hormonal contraceptives cause weight gain?

Evidence-Based Answer

There is no causal relationship between combination contraceptives and weight gain.

Practice Pointers

Many women and physicians believe that weight gain is associated with combination hormonal contraceptives. The weight gain could be the result of water retention, increased muscle mass, or increased fat deposition. To test this perception, Gallo and colleagues performed a systematic review of randomized controlled trials. They included studies of at least three menstrual cycles' duration that compared combination contraceptives with placebo or other drugs, dosages, regimens, or study lengths. They found three placebo-controlled trials, none of which found a significant difference in weight gain between groups. The largest of these studies, with 473 patients, found a difference of less than 1 lb after six months. There was also no difference between groups in discontinuation of the contraceptives because of weight gain. Furthermore, most of the studies comparing two contraceptive regimens did not show differences in weight gain.

When patients are reluctant to take combination contraceptives because they fear weight gain, physicians can tell them that it is true that women gain weight with the pill and the patch. However, they also gain weight when they don't use these products. Physicians can direct them to the excellent resources on healthy lifestyles that have been developed by the National Institutes of Health.1 The "Aim for a Healthy Weight” program has an interactive Web site on diet and exercise for patients (http://www.nhlbi.nih.gov/health/public/heart/obesity/lose_wt/).

CLARISSA KRIPKE, M.D.

Gallo MF, et al. Combination contraceptives: effects on weight. Cochrane Database Syst Rev, 2004;(3):CD003987.

REFERENCES

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