This is the current release of the guideline.

Croup

To evaluate, in children with croup seen in the Emergency Department, if the use of steroids versus no steroid decreases duration of symptoms and/or length of stay

Inclusion: Children 0 to 18 years of age that present to the Emergency Department with mild, moderate, or severe croup

Exclusion: Children unable to tolerate glucocorticoids (prior history of adverse effect) or have already received a dose prior to Emergency Department visit

Databases: Ovid Medline

#1

1. Croup mp. Or exp Croup
2. Limit 1 (English language and humans and yr="2006-Current")
3. Limit 2 ("all infant [birth to 23 months]" or "all child [0 to 18 years]" or "newborn infant [birth to 1 month]" or "infant [1 to 23 months]" or "preschool child [2 to 5 years]" or "child [6 to 12 years]" or "adolescent [13 to 18 years]")
4. Steroids mp. Or exp Steroids
5. Limit 3 and 4

#2

1. Croup mp. Or exp Croup
2. Exp steroids Steroids/or steroids.mp.
3. 1 and 2
4. Limit 3 to (English language and humans and yr="2006-Current")

#3

Additional articles identified from reference lists of retrieved articles

Not stated

Table of Evidence Levels

^†a = good quality study; b = lesser quality study

Note: See the original guideline document for further information about the dimensions used to judge the strength of the evidence.

Not stated

Not stated

Table of Recommendation Strength

A formal cost analysis was not performed and published cost analyses were not reviewed.

This Best Evidence Statement has been reviewed against quality criteria by 2 independent reviewers from the Cincinnati Children's Hospital Medical Center (CCHMC) Evidence Collaboration.

The strength of the recommendation (strongly recommended, recommended, or no recommendation) and the quality of the evidence (1a‒5b) are defined at the end of the "Major Recommendations" field.

It is strongly recommended that a single dose of glucocorticoids be administered to children presenting to the Emergency Department with mild, moderate or severe croup (Russell et al., 2011 [1a]; Chub-Uppakarn & Sangsupawanich, 2007 [2b]; Dobrovoljac & Geelhoed, 2009 [4a]; Borland et al., 2008 [4a]; Port, 2009 [5a]; Syed et al., 2009 [5a]; Royal Children's Hospital, 2011 [5b]; Rajapaksa & Starr, 2010 [5b]).

Note 1: Children receiving steroids in the Emergency Department demonstrated significant improvement in symptoms and fewer return visits and/or (re)admissions as compared to placebo (Russell et al., 2011 [1a]).

Note 2: No conclusive studies exist, recommending one drug, dose or route over another for the treatment of croup. However, the oral route may be preferred due to the non-invasive nature causing less stress to the child, although intramuscular (IM), intravenous (IV) or nebulized routes may be useful in children especially those unable to tolerate medications via the oral route (Russell et al., 2011 [1a]; Local Consensus, 2011 [5]; Syed et al., 2009 [5a]).

Note 3: Patients receiving dexamethasone versus prednisolone in the treatment of croup demonstrated a statistically significant decreased likelihood of return visit/readmission compared to those receiving prednisolone, although clinical scores did not differ (Russell et al., 2011 [1a]).

Note 4: Children with severe croup may require additional, more aggressive therapies (Syed et al., 2009 [5a]).

Definitions:

Table of Evidence Levels

^†a = good quality study; b = lesser quality study

Note: See the original guideline document for further information about the dimensions used to judge the strength of the evidence.

Table of Recommendation Strength

None provided

The type of supporting evidence is identified and graded for each recommendation (see the "Major Recommendations" field).

Glucocorticoid treatment of croup has consistently demonstrated improvements in symptoms as demonstrated by improved croup scores, within 6 hours, lasting for about 12 hours, decreased use of epinephrine, shortened hospital stays by 12 hours, and reduced subsequent visits or readmissions.

Not stated

This Best Evidence Statement addresses only key points of care for the target population; it is not intended to be a comprehensive practice guideline. These recommendations result from review of literature and practices current at the time of their formulation. This Best Evidence Statement does not preclude using care modalities proven efficacious in studies published subsequent to the current revision of this document. This document is not intended to impose standards of care preventing selective variances from the recommendations to meet the specific and unique requirements of individual patients. Adherence to this Statement is voluntary. The clinician in light of the individual circumstances presented by the patient must make the ultimate judgment regarding the priority of any specific procedure.

An implementation strategy was not provided.

Not applicable: The guideline was not adapted from another source.

Cincinnati Children's Hospital Medical Center

Not stated

Team Leader/Author: Joe Luria, MD/Emergency Medicine

Team Members/Co-Authors: Christine White, MD, MAT/General Pediatrics, Michelle Caruso, PharmD, BCPS/Pharmacy

Support/Consultant: Wendy Engstrom Gerhardt, MSN, RN-BC/James M. Anderson Center for Health Systems Excellence

Conflicts of interest were declared for each team member and no financial conflicts of interest were found.

This is the current release of the guideline.

Electronic copies: Available from the Cincinnati Children's Hospital Medical Center Web site .

Print copies: For information regarding the full-text guideline, print copies, or evidence-based practice support services contact the Children's Hospital Medical Center Health Policy and Clinical Effectiveness Department at HPCEInfo@chmcc.org.

The following are available:

• Judging the strength of a recommendation. Cincinnati (OH): Cincinnati Children's Hospital Medical Center; 2008 Jan. 1 p. Available from the Cincinnati Children's Hospital Medical Center Web site .
• Grading a body of evidence to answer a clinical question. Cincinnati (OH): Cincinnati Children's Hospital Medical Center; 1 p. Available from the Cincinnati Children's Hospital Medical Center Web site .
• Table of evidence levels. Cincinnati (OH): Cincinnati Children's Hospital Medical Center; 2008 Feb 29. 1 p. Available from the Cincinnati Children's Hospital Medical Center Web site .

Print copies: For information regarding the full-text guideline, print copies, or evidence-based practice support services contact the Children's Hospital Medical Center Health Policy and Clinical Effectiveness Department at HPCEInfo@chmcc.org.

In addition, a suggested outcome measure is available in the original guideline document .

The following is available:

• Croup. Electronic copies: Available in English  and Spanish  from the Cincinnati Children's Hospital Medical Center Web site.

Please note: This patient information is intended to provide health professionals with information to share with their patients to help them better understand their health and their diagnosed disorders. By providing access to this patient information, it is not the intention of NGC to provide specific medical advice for particular patients. Rather we urge patients and their representatives to review this material and then to consult with a licensed health professional for evaluation of treatment options suitable for them as well as for diagnosis and answers to their personal medical questions. This patient information has been derived and prepared from a guideline for health care professionals included on NGC by the authors or publishers of that original guideline. The patient information is not reviewed by NGC to establish whether or not it accurately reflects the original guideline's content.

This NGC summary was completed by ECRI Institute on March 28, 2012.

This NGC summary is based on the original full-text guideline, which is subject to the following copyright restrictions:

Copies of Cincinnati Children's Hospital Medical Center (CCHMC)  Best Evidence Statement (BESt) are available online and may be distributed by any organization for the global purpose of improving child health outcomes. Examples of approved uses of the BESt include the following:

• Copies may be provided to anyone involved in the organization's process for developing and implementing evidence based care
• Hyperlinks to the CCHMC website may be placed on the organization's website
• The BESt may be adopted or adapted for use within the organization, provided that CCHMC receives appropriate attribution on all written or electronic documents
• Copies may be provided to patients and the clinicians who manage their care

Notification of CCHMC at HPCEInfo@cchmc.org for any BESt adopted, adapted, implemented or hyperlinked by the organization is appreciated.