Parker CM and Cooper MN. Prednisolone Versus Dexamethasone for Croup: a Randomized Controlled Trial. Pediatrics. 2019;144(3):e20183772
Comment from Yan:
Parker et al concluded that there is no significant difference between dexamethasone 0.6mg/kg, 0.15 mg/kg and prednisolone at 1 mg/kg in the treatment of croup in this prospective, double-blind, noninferiority randomised controlled trial in an Australian tertiary ED paediatric population. Primary outcomes were an hourly croup score and 7 days re-attendance rate.
My biggest criticism of this otherwise well carried out trial was that only 1 in 7 croup cases were enrolled (deemed ‘convenience sample’). There was also no analysis to look at any potential differences between the enrolled and non enrolled group. The study in the end did not achieve the pre-determined target number of subjects for the non inferiority analysis, but the confidence intervals clearly overlap across the groups.
Also 30% of enrolled patients did not have phone follow up (meaning GP re-attendance not accounted for in this group). Note also that the single dose prednisolone 1mg/kg group is more likely to require further doses of steroids than the dexamethasone groups. I think this study still doesn’t answer the question about which steroid to give these kids conclusively.
In practice, this study seems not to contradict what is probably the most common practice in rural—for the bulk of croup patients, prescribe single dose oral dexamethasone if available or a course of prednisolone if not (Starship recommends 2 days at 1mg/kg.)
OBJECTIVES: The use of either prednisolone or low-dose dexamethasone in the treatment of childhood croup lacks a rigorous evidence base despite widespread use. In this study, we compare dexamethasone at 0.6 mg/kg with both low-dose dexamethasone at 0.15 mg/kg and prednisolone at 1 mg/kg.
METHODS: Prospective, double-blind, noninferiority randomized controlled trial based in 1 tertiary pediatric emergency department and 1 urban district emergency department in Perth, Western Australia. Inclusions were age >6 months, maximum weight 20 kg, contactable by telephone, and English-speaking caregivers. Exclusion criteria were known prednisolone or dexamethasone allergy, immunosuppressive disease or treatment, steroid therapy or enrollment in the study within the previous 14 days, and a high clinical suspicion of an alternative diagnosis. A total of 1252 participants were enrolled and randomly assigned to receive dexamethasone (0.6 mg/kg; n = 410), low-dose dexamethasone (0.15 mg/kg; n = 410), or prednisolone (1 mg/kg; n = 411). Primary outcome measures included Westley Croup Score 1-hour after treatment and unscheduled medical re-attendance during the 7 days after treatment.
RESULTS: Mean Westley Croup Score at baseline was 1.4 for dexamethasone, 1.5 for low-dose dexamethasone, and 1.5 for prednisolone. Adjusted difference in scores at 1 hour, compared with dexamethasone, was 0.03 (95% confidence interval −0.09 to 0.15) for low-dose dexamethasone and 0.05 (95% confidence interval −0.07 to 0.17) for prednisolone. Re-attendance rates were 17.8% for dexamethasone, 19.5% for low-dose dexamethasone, and 21.7% for prednisolone (not significant [P = .59 and .19]).
CONCLUSIONS: Noninferiority was demonstrated for both low-dose dexamethasone and prednisolone. The type of oral steroid seems to have no clinically significant impact on efficacy, both acutely and during the week after treatment.
Yan Wong is a rural doctor in Balclutha, Otago. He is also a convener for the GENA725 – Communication in Rural Hospital Medicine, which is running in semester 1 of this year. This course covers palliative care, Māori health, mental health, alcohol and drugs/addiction among other things, all with a rural context focus. The residential is based on a marae in the beautiful Hoikianga