Aim A systematic review of 43 randomised controlled trials (RCTs) concluded that single dose oral dexamethasone is effective in the treatment of croup. Dexamethasone was associated with an improved Westley score at 6 h to 12 h with an effect size of –1.0 (95% CI –1.5 to –0.6) which was significant, but was no longer significant at 24 h. To date, no RCTs have determined whether administering two doses of dexamethasone, compared with a single dose, improves outcomes in children with croup. We completed an audit to review the use of dexamethasone in children with croup.
Method Inpatient notes of 50 children admitted between 2010 and 2011 were reviewed at a district general hospital. To gauge the readmission rate, a comparative notes review was performed for attendances at the Emergency Department of a local tertiary paediatric centre (150 attendances, June–November 2014).
Results Figure 1 shows results at the district general hospital
Half of the children who required readmission had the same croup score on their first admission and their second, implying that readmission was necessary due to lack of clinical improvement. At the tertiary centre, 90% (135) patients received a dose of dexamethasone on their first presentation and 10% (15) children re-attended.
With 1 in 10 patients being readmitted despite one dose of dexamethasone, we conducted a regional survey of paediatricians in our deanery to assess baseline practice for multi-dose dexamethasone. The survey contained a hypothetical case scenario of a child with croup (stridor and chest wall retraction at rest) who received a dose of dexamethasone. At 12 h the patient improved with no symptoms at rest but symptoms on exertion. Respondents were given four management options, as shown in Table 1. A total of 112 responses were received, 44% from consultants.
The results demonstrate a wide variation in practice. 23% of respondents stated that their choice was based on trust guidelines, whereas 77% stated it was personal practice.
Conclusion The high readmission rate, variation in practice and lack of evidence for administering a second dose of dexamethasone in croup suggest this is a topic that would benefit from a research project.
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