As the season of croup is upon us (in the UK at any rate) I have used Visual Rx to demonstrate the benefits of the use of oral or inhaled steroids in preventing admission to hospital (or readmission in the case of the primary trials which have all been carried out in secondary care settings).

Before you say that we should not rely on data from secondary care for guiding practice in primary care, I would ask the question: “Are there important differences between the patients in these studies and those that we see in primary care?”  I would think not, except that we probably see the milder end of the spectrum, which means that the number needed to treat to avoid admission in our patients may be higher than in these trials.  Whilst we await primary care studies, I shall go on using the most valid available evidence from secondary care to inform my practice.

There is a further practical issue before we go on to look at the results of the Cochrane review of this subject.  The trials used nebulised Budesonide or oral Dexamethasone syrup made up by the hospital pharmacy.  No great differences have been shown between the benefits from the oral or nebulised treatment.  In practice nebulised Budesonide is very expensive and quickly goes out of date.  I would therefore suggest oral Betamethasone tablets (which are easily available in primary care and dissolve easily and relatively taste-free into a small drink).  The dose is 0.15mg per kg as Betamethasone and Dexamethasone are equipotent.

This is not a new suggestion but was in a letter that I wrote to the BMJ a year or two ago now (http://bmj.com/cgi/content/full/319/7224/1577/a ). Our experience has been very positive since we adopted the use of oral Betamethasone, and we have few children admitted to hospital with croup now.

There is of course the parental worry about giving steroids to their child, so we need to look at how much difference the treatment makes.  A review of the evidence (http://www.bmj.com/cgi/content/full/319/7210/595 )was published in 1999 in the BMJ and will also be updated on the Cochrane Library

The results are presented as shorter times being treated in Casualty or as In-Patients, but outcomes are also given for improvement at 6 and 12 hours and reduction in the risk of readmission.  The Number Needed to Treat to prevent one re-admission and for an extra child to improve at 12 hours are shown on the graphical displays below.

On a practical point as the outcome of improvement at 6 hours is beneficial you need to uncheck the adverse outcome box in Visual Rx before entering the control event rate and Odds Ratio or Relative Risk generated by the Cochrane Review (if you want to have a go at making the pictures yourself).  Otherwise I have put them on the next page.  As usual the green faces are fine whether given steroids or not, and the red ones have a poor outcome either way.  The yellow faces are the ones that will change outcome for the better if given treatment, and the catch is that we do not know which these are, so all 100 have to have the treatment.