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COMMENTARY |
Departments of Pediatrics, Pharmacology, and Community Health Sciences
University of Manitoba
Children’s Hospital
Winnipeg, Manitoba, R3E 1S1
Canada
Steroids are not indicated in the management of croup; I still have the pre-PowerPoint slides that say so. I used them for my resident teaching sessions of 3 decades ago. Today’s slides (we need a better term for our electronically stored, digitized images that are projected directly as the need arises) herald the opposite, ie, steroids are the standard of care in the management of croup. Segal et al,1 in this issue of Pediatrics, documented an 86% decrease in the number of hospital admissions for treatment of croup in Ontario, Canada, between 1993 and 2002. This change coincided with the adoption of outpatient glucocorticoid therapy for croup. Therefore, the observations by Segal et al1 can be viewed as outcome data supporting the efficacy of glucocorticoid therapy for this disease. This prompts a brief review of the steroid odyssey in croup.
Perhaps the most notable early challenge of the anti-steroid dogma was Coffin’s oft-cited 1971 letter to the editor titled, "Corticosteroids in Croup: Is There a Reply From the Ivory Tower?"2 Previous clinical trials reported in influential journals did not support efficacy.3,4 In 1979, the publication of a reasonably performed clinical trial demonstrating benefit from dexamethasone5 did not seem to tilt the ivory tower, as evidenced by an accompanying negative editorial.6 The turning point was the 1989 meta-analysis by Kairys et al,7 which reviewed the 9 methodologically satisfactory trials (5 positive and 4 negative) of glucocorticoids in croup. The principal outcomes were clinical improvement at 12 and 24 hours and decreased rates of tracheal intubation. The investigators found improved odds ratios for all 3 of these criteria and a dose-response relationship for these outcomes. Kairys et al7 concluded that "this meta-analysis supports the practice of using steroids to treat patients ill enough to be hospitalized for croup."
The next logical question was to ask whether glucocorticoids would benefit children with croup not ill enough to require hospitalization. Terry Klassen, who was destined to become the cutting-edge croup investigator who would change the treatment of children with mild/moderate disease, published the first study in 1994.8 In their randomized, clinical trial, Klassen et al8 found "a prompt and important improvement in children with mild-to-moderate croup who come to the emergency department." Multiple corroborative studies, performed by Klassen and by others, and subsequent meta-analyses9,10 established firmly glucocorticoid therapy as the standard of care for croup both in and out of the hospital. A recent, randomized, clinical trial involving children with mild croup (disease so mild that pharmacotherapy was controversial) found that, among those treated with dexamethasone, fewer returned for medical care because of croup and there was more rapid clinical improvement, reduced loss of sleep, and less stress for parents.11
There is other evidence in the literature that glucocorticoid therapy reduces hospital admissions because of croup. Geelhoed,12 in Perth, Australia, documented fewer hospital admissions from an emergency department observation unit after glucocorticoid therapy became mandatory. A 13-fold decrease in admission rates for croup between 1991 and 1996, after the adoption of glucocorticoid therapy, was documented in our institution.13 For the preparation of this commentary, I asked our health records department to report on the number of croup admissions for the years 1988–2002, the same period studied by Segal et al.1 There were 191 and 75 admissions in the 3-year periods of 1988–1990 and 2000–2002, respectively, representing a 60% decrease, which is very similar to the 86% decrease reported by Segal et al.1
Slides of the pre-PowerPoint era were prepared differently. Characters were typed with a high-resolution typewriter on nonglare paper, the image was photographed, and the photograph was developed. If color was desired to highlight a phrase or title, then we painted it by hand directly on the slide, with translucent enamels of various hues. Although these slides were not chiseled in stone, change, understandably, was not taken lightly. Therefore, data had to be scientifically convincing long before the phrase "evidence-based" had permeated academic medicine. Change is easier with PowerPoint, but it is hoped that the standard of evidence required to support a change of opinion has not diminished. The weight of evidence for glucocorticoids in croup makes this concern irrelevant.
An observation by Jean Martin Charcot (1825–1893) might well apply to the steroid odyssey in croup. "Disease is very old, and nothing about it has changed. It is we who change, as we learn to recognize what was formerly imperceptible."
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FOOTNOTES |
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Address correspondence to Milton Tenenbein, MD, Department of Pediatrics, University of Manitoba, Children’s Hospital, 840 Sherbrook St, Winnipeg, Manitoba, R3E 1S1, Canada. E-mail: mtenenbein{at}hsc.mb.ca
No conflict of interest declared.
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REFERENCES |
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 TOP REFERENCES |
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This article has been cited by other articles:
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  J. D. Cherry Croup N. Engl. J. Med., January 24, 2008; 358(4): 384 - 391. [Full Text] [PDF]
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