Drs Jack Beattie and James Paton explain how a local, joint guideline recommending early treatment with corticosteroids significantly improved outcomes in croup


Drs Jack Beattie and James Paton explain how a local, joint guideline recommending early treatment with corticosteroids significantly improved outcomes in croup

Laryngotracheobronchitis is a common cause of upper airway obstruction in children. The presenting symptoms are characteristic – hoarseness, a barking cough, and acute inspiratory stridor (croup). The symptoms are usually due to viral infection, most commonly with parainfluenza virus type 1, causing oedema of the larynx and trachea.

The size of the problem

Although usually a self-limiting illness, croup causes parental anxiety and imposes a large burden on healthcare systems.

It affects around 3% of children younger than 6 years each year,1 and has a peak incidence in the second year of life.

Although the vast majority of children with croup are managed in the community, there is a surprising lack of evidence about children presenting with croup in primary care.

A significant proportion of children also present to hospital with acute croup. Children with croup account for 2–3% of acute paediatric inpatient admissions.2

Admission rates in children assessed in outpatient settings range from 1.5% to 31% of cases seen, depending on hospital admission policies, the severity of the disease, and the social and other characteristics of the population being assessed.

Evidence for the use of steroid therapy in croup

There is now substantial evidence clearly supporting the routine use of oral,3, 4 parenteral,5 or nebulised6 corticosteroids for children admitted with croup.

There is also firm evidence that oral dexamethasone or nebulised budesonide results in clinical improvement in outpatients with mild to moderate croup, reducing the need for admission.7,8

One oral dose of dexamethasone (0.15mg/kg) is effective in reducing the need for further medical care in mild croup.9 Prednisolone has not been widely studied (equivalent dose 1mg/kg), but there is no reason to suppose it would be less effective.

Corticosteroid therapy for croup reduces:

  • The severity of the respiratory symptoms within 5 hours (in some studies, in as little as one hour) that lasts at least 12 hours
  • The need for additional treatment such as nebulised epinephrine (adrenaline)
  • The time spent in A&E
  • The need for hospitalisation after observation in A&E/assessment units
  • Re-attendance to any medical practitioner in the week after discharge
  • The length of inpatient care
  • The need for admission to ITU
  • The need for intubation.

Much of the early concern about dexamethasone and other corticosteroids for children with croup focused on the potential for adverse effects.

Although significant complications such as gastrointestinal bleeding are occasionally seen in children with critical illness such as meningitis who are also given corticosteroid therapy,10 this has not been as common in children with less severe illness. In a review of 649 children with croup who received single-dose or short-term corticosteroids no adverse effects were reported.11

In recent years, additional experience from the increased use of corticosteroids to treat acute asthma has reduced concerns about harm. The risk-benefit balance has shifted clearly in favour of corticosteroids.

Why did we develop a local guideline?

During the early 1990s, croup represented the sixth most common diagnosis leading to acute medical admission to the Royal Hospital for Sick Children, Glasgow.

In 1994/95, we recorded 445 in-patient admissions with croup.12 Furthermore, 17 of these children needed admission to ITU because of croup. Thus the condition reflected a substantial clinical burden.

In early 1996, in response to escalating acute medical referrals for in-patient care, we opened a short stay ward (SSW) adjacent to our A&E department. The initial eight beds expanded to 10 beds in late 1996. A full-time consultant paediatrician (JB) was appointed Head of Service in early 1997.

Around 10 000 children with acute medical conditions are referred for secondary assessment to the SSW each year – 60% from GPs and 30% from A&E departments.

After assessment, treatment and observation, two-thirds of SSW attendances can be discharged, resulting in a significant reduction in conventional inpatient care.

During the mid and late 1990s, it became routine for us to prescribe corticosteroid therapy (oral or nebulised) to all children referred with croup. This policy, together with the impact of the SSW ambulatory approach to acute care led to a significant reduction in inpatient admissions with croup.

During the first 6 months of 1998 we audited the pre-admission use of corticosteroid therapy in children referred to the SSW with a diagnosis of croup. We found that only 5 of 139 children (4%) had been given any form of corticosteroid treatment before RSW admission. A similar picture has been reported from other UK paediatric units.13,14

This finding was disappointing since early pre-hospital use should improve symptoms, shorten the duration of observation and perhaps further reduce the need for subsequent inpatient care.

How did we develop our guideline?

In early 1999, we approached local family doctors from the primary care trust and GP out-of-hours cooperative (Glasgow Emergency Medical Services [GEMS]) with a view to developing a number of joint clinical guidelines for the management of common paediatric emergencies; the first was for the management of croup.

GEMS is the largest such service in the UK, with around 250000 patient contacts each year, one-third of whom are children.

We believed that to make any impact on professional practice, it was important to involve clinicians from the relevant target group, to ensure that there was joint ownership of the development, and to maximise the potential for change in practice. A small guideline development group met on several occasions.

Figure 1: Guideline on the emergency management of croup*
guideline - emergency management of croup

The guideline (see Figure 1, above) focused on several aspects of croup management:

  • Diagnosis and exclusion of alternative pathologies
  • Clinical assessment of the severity of croup
  • Recommended universal use of corticosteroid treatment in children with croup, irrespective of severity
  • A simple dosage regimen based on age
  • Selection of cases for hospital referral
  • Management of the children with severe croup in the community

Since nebulised corticosteroid therapy is relatively expensive and often associated with emotional distress during treatment,15 and since there is no evidence that nebulised therapy is superior to systemic therapy we recommended oral soluble prednisolone.

We confirmed acceptability of the final version of the guideline with the local primary care prescribing advisor.

Dissemination of the guideline

The guideline was widely distributed within the region:

  • A copy was sent to each family doctor within the Greater Glasgow Health Board area, accompanied by a covering letter signed by all members of the guideline development group and the public health consultant responsible for child health commissioning.
  • Copies were distributed to all A&E departments within the region.
  • Copies were made available to all new A&E SHOs during their induction course.
  • The guideline was made available on the hospital academic website: (http://www.gla.ac.uk/departments/yorkhill/pdf/croup.pdf).

Supporting educational programme

Even before the development and launch of the guideline, a series of educational events on paediatric clinical practice were held at which the use of steroids in croup was promoted.

Primary care

Following distribution of the guideline, an annual series of paediatric educational events was instituted. These include an interactive session using acute paediatric clinical situations. Croup is included in this session, and further copies of the guideline are made available.

In addition, all family doctors working for the GEMS service attended one of a series of mandatory educational events focusing on acute paediatric topics, which included assessment and treatment of croup.

The topic is included in paediatric teaching sessions for GP registrars, and copies of the guideline are again distributed.

Accident & emergency

Treatment of croup was included in the paediatric component of the twice-yearly induction course and new A&E SHOs employed in local adult A&E services.

It also features in interactive paediatric clinical scenarios used in teaching sessions for the West of Scotland Postgraduate Medical Educational programme for A&E specialist registrars.

Hospital paediatrics

The universal use of corticosteroid therapy in croup is included in training sessions for SHOs working in our hospital, who are in the early phase of specialist training or vocational training for general practice.

Impact on patient care

Change in the use of pre-hospital corticosteroid treatment

We compared the use of steroid treatment in children referred during the first 6 months of 1998, 1999 and 2000 (see Table 1).

Table 1: Trends in treatment with pre-referral corticosteroids over the first 6 months of the 3 years 1998-2000*

Referral source 1998 1999 2000
A&E 3% 79% 79%
GEMS 6% 50% 75%
GP 9% 20% 32%

* The guideline was distributed to GPs in 1999
GEMS = Glasgow Emergency Medical Services

The impact of the guideline/ educational programme was very significant in children referred from the GEMS service. Here, steroid use rose 13-fold compared with 3-fold for referrals from the child's own GP.

The most marked increase in use was in children referred by the A&E service, with steroid use rising 76% over the 3 years.

Trend in referral numbers

We have also seen a significant change in the number of children referred with croup.

Overall, there has been a 56% reduction in children referred with croup over those three periods (Figure 2). This was due to a reduction in A&E (-62%) and GEMS (-43%) referrals.

Figure 2: Trend in referrals and pre-hospital steroid treatment (SRx) over the first 6 months of 1998-2000
bar chart

Surprisingly, there was no change in referral numbers from family doctors caring for their own practice patients, despite most of these children being seen and referred during the day, when one would assume that parental anxiety was lower than out of hours.

Impact on illness severity at hospital

In year two of the study, clinical assessment on arrival showed a significant reduction in the degree of respiratory distress in children who had received treatment before referral. In addition, those children could be discharged more rapidly after observation.

These differences had disappeared by the third year of the study, suggesting that there was an increasing selection of ill children for referral, coinciding with the reduction in overall referral numbers.

Effect on need for inpatient care

Pre-hospital corticosteroid treatment had an impact on the need for subsequent admission after assessment.

When we compared the outcome of 517 sequential referrals with croup to our SSW, we found that 19 of 181 children (10.5%) treated with pre-hospital steroids progressed to full hospital admission after assessment compared with 55 of 336 children (16.4%) not given steroids.

Conclusions

A consistent body of evidence from randomised controlled trials now substantiates the efficacy of corticosteroid therapy for children with croup,16,17 which was once thought controversial.

It is no longer reasonable to conclude that the use of corticosteroids should be reserved for individuals who are hospitalised with moderate-to-severe croup.18

We have demonstrated that, in partnership with primary care colleagues, it is possible to develop and introduce an evidence-based guideline that can significantly influence the pre-hospital care of acutely ill children.

Not only did we appreciably reduce hospital referral of children with croup, but we also made a significant impact on the use of pre-hospital corticosteroid treatment in those who were referred.

Although the overall rate of inpatient admission to our hospital with croup is currently stable at around 25% of the rate seen in the early 1990s, much of the reduction can be attributed to the introduction of our acute ambulatory care programme focused on our SSW, together with the now universal use of corticosteroids on arrival at hospital.

Furthermore, the use of pre-hospital corticosteroid resulted in a reduction in illness severity on arrival, and a shortened length of stay in those discharged after observation.

Such success in working in partnership across the primary-secondary care interface to develop and implement evidence-based guidelines is rare.

The relationships developed offer a sound foundation for future projects, which can only be in the best interests of sick children and their families.

References

  1. Denny FW, Murphy TF, Clyde WA, Collier AM, Henderson FW. Croup: an 11 year study in pediatric practice. Pediatrics 1983; 71: 871-6.
  2. Phelan PD, Landau LI, Olinsky A. Respiratory Illness in Children. 3rd edn. Oxford: Blackwell Scientific Publications, 1990: 54-60.
  3. Skowron PN, Turner JAP, McNaughton GA. Use of corticosteroid (dexamethasone) in the treatment of acute laryngotracheitis. Can Med Assoc J. 1966; 94: 528-31.
  4. Tibbals J, Shann FA, Landau LI. Placebo-controlled trial of prednisolone in children intubated for croup. Lancet 1992; 340: 745-8.
  5. Kuusela AL, Vesikari T. A randomized double-blind, placebo-controlled trial of dexamethasone and racemic epinephrine in the treatment of croup. Acta Paediatr 1988; 77: 99-104.
  6. Husby S, Agertoft L, Mortensen S, Pedersen S. Treatment of croup with nebulised steroid (budesonide): a double blind, placebo controlled study. Arch Dis Child 1993; 68: 353-5.
  7. Klassen TP, Feldman ME, Watters LK, Sutcliffe T, Rowe PC. Nebulized budesonide for children with mild-to-moderate croup. N Engl J Med 1994; 331: 285-9.
  8. Cruz MN, Stewart G, Rosenberg N. Use of dexamethasone in the outpatient management of acute laryngotracheitis. Pediatrics 1995; 96: 220-3.
  9. Geelhoed G, Turner J, Macdonald W. Efficacy of a small single dose of oral dexamethasone for outpatient croup: a double blind placebo controlled clinical trial. Br Med J 1996; 313: 140-2.
  10. Lebel MH, Freij BJ, Syriogiannopoulos GA et al. Dexamethasone therapy for bacterial meningitis: results of two double-blind, placebo-controlled trials. N Engl J Med 1988; 319: 964-71.
  11. Kairys SW, Olmstead EM, O'Connor GT. Steroid treatment of laryngotracheitis: a meta-analysis of the evidence from randomized trials. Pediatrics 1989; 83: 683-93.
  12. Data from Information & Statistics Division, Common Services Agency, Scottish Executive.
  13. Jothimurugan S, Hassan Z, Silverman M. Effectiveness of glucocorticoids in treating croup: children with croup should receive corticosteroids in primary care: results of audit. Br Med J 1999: 319; 1577.
  14. Tillett AJ, Gould JDM. General practitioners must be ready to treat children. Br Med J 1999; 319: 1577.
  15. Roberts GW, Master VV, Staugas RE et al. Repeated dose inhaled budesonide versus placebo in the treatment of croup. J Paediatr Child Health 1999; 35: 170-4.
  16. Ausejo M, Saenz A, Pham 'B et al. The effectiveness of glucocorticoids in treating croup: meta-analysis. Br Med J 1999; 319: 595-600.
  17. Osmond M, Evans D. Croup. Clinical Evidence 2000; (www.clinicalevidence.org).
  18. Welliver RC. Croup: continuing controversy. Semin Pediatr Infect Dis 1995; 6: 90-5.

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Guidelines in Practice, March 2001, Volume 4(3)
© 2001 MGP Ltd
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