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<< An Evidence-Based Approach To The Evaluation And Treatment Of Croup In Children


Evidence-based medicine requires a critical appraisal of the literature based upon study methodology and number of subjects. Not all references are equally robust. The findings of a large, prospective, randomized, and blinded trial should carry more weight than a case report.

To help the reader judge the strength of each reference, pertinent information about the study, such as the type of study and the number of patients in the study will be included in bold type following the references, where available. The most informative references cited in this paper, as determined by the author, will be noted by an asterisk (*) next to the number of the reference.

  1. Bjornson C, Russell KF, Vandermeer B, et al. Nebulized epinephrine for croup in children. Cochrane Database Syst Rev. 2011,16;(2): CD006619. (Systematic review; 8 studies; 225 patients)
  2. Russell KF, Liang Y, O’Gorman K, et al Glucocorticoids for croup. Cochrane Database Syst Rev. 2011,19;(1):CD001955. (Systematic review; 24 studies; 2878 patients)
  3. Vorwek C, Coats T. Heliox for croup in children. Cochrane Database Syst Rev. 2010,17;(2):CD006822. (Systematic review; 2 studies; 44 patients)
  4. Moore M, Little P. Humidified air inhalation for treating croup. Cochrane Database Syst Rev. 2006,19;(3):CD002870. (Systematic review)
  5. Infectious Diseases and Immunization Committee. Canadian Paediatric Society. Steroid therapy for croup in children admitted to hospital. CMAJ. 1992; 147(4):429-432. (Position statement)
  6. * Alberta Clinical Practice Guideline Working Group. Guideline for diagnosis and management of croup. 2007 Update. Available at: http://www.albertadoctors.org/bcm/ama/ama-website.nsf/AllDoc/87256DB000705C3F87256E05005534E2/$File/CROUP.PDF. Accessed October 2, 2011. (Clinical guidelines)
  7. Eden AN, Larkin VP. Corticosteroid treatment of croup. Pediatrics. 1964;33(5):768-769. (Randomized controlled trial; 41 patients)
  8. Turner JA, Morgan EA. Corticotropin (ACTH) in the treatment of acute laryngotracheitis. Amer J Dis Child. 1952;83(4):440-445.
  9. Martensson B, Nilson B. The effect of corticosteroids in the treatment of pseudo-croup. Acta Otolaryngol. 1960;158(suppl): 52. (Randomized controlled trial; 288 patients)
  10. Novik A. Corticosteroid treatment of non-diphtheric croup. Act Otolaryngol. 1960;158(suppl):20. (Randomized controlled trial; 160 patients)
  11. James J. Dexamethasone in croup. Am J Dis Child. 1969;117(5):511-516. (Randomized controlled trial; 88 patients)
  12. Koren G, Frand M, Barzilay Z, et al Corticosteroid treatment of laryngotracheitis v spasmodic croup in children. Am J Dis Child. 1983;137(10):941-944. (Randomized controlled trial; 72 patients)
  13. * Kairys SW, Olmstead EM, O’Connor GT. Steroid treatment of laryngotracheitis: a meta-analysis of the evidence from randomized trials. Pediatrics.1989; 83(5):683-693. (Meta-analysis, 10 studies; 1286 patients)
  14. Zach M, Erben A, Olinsky A. Croup, recurrent croup, allergy, and airways hyper-reactivity. Arch Dis Child. 1981;56(5):336-341. (Cohort study; 110 patients)
  15. Cohen B, Dunt D. Recurrent and non-recurrent croup: an epidemiological study. Aust Paediatr J. 1988;24(6):339-342 (Case-control study; 137 patients)
  16. Edwards KM, Dundon MC, Altemeier WA. Bacterial tracheitis as a complication of viral croup. Pediatr Infect Dis. 1983;2(5):390-391. (Case reports; 2 patients)
  17. Rosychuk, RJ, Klassen TP, Metes D, et al Croup presentations to emergency departments in Alberta, Canada: a large population-based study. Pediatr Pulmonol. 2010;45(1):83-91. (Retrospective study; 27,355 ED visits)
  18. * Rosychuk RJ, Klassen TP, Voaklander DC, et al. Seasonality patterns in croup presentations to emergency departments in Alberta, Canada: a time series analysis. Pediatr Emerg Care. 2011;27(4):256-260. (Retrospective study; 27,355 ED visits)
  19. McEniery J, Gillis J, Kilham H, et al. Review of intubation in severe laryngotracheobronchitis. Pediatrics. 1991;87(6):847-853. (Retrospective chart review; 208 patients)
  20. Knott AM, Long CE, Hall CB. Parainfluenza viral infections in pediatric outpatients: seasonal patterns and clinical characteristics. Pediatr Infect Dis J. 1994;13(4):269-273. (Prospective surveillance study; 5998 patients)
  21. Wall SR, Wat D, Gelder CM, et al. The viral aetiology of croup and recurrent croup. Arch Dis Child. 2009;94(5):359-360. (Prospective study; 60 patients)
  22. Chapman RS, Henderson FW, Clyde WA, et al The epidemiology of tracheobronchitis in pediatric practice. Am J Epidemiol. 1981;114(6):786-797. (Epidemiological study; 1824 patients)
  23. Hussey GD, Clements CJ. Clinical problems in measles case management. Ann Trop Paediatr. 1996;16(4):307-317. (Review article)
  24. Burton DM, Seid AB, Kearns DB, et al. Candida laryngotracheitis: a complication of combined steroids and antibiotic usage in croup. Int J Pediatr Otorhinolaryngol. 1992;23(2):171-175. (Case report)
  25. Sobol SE, Zapata S. Epiglottitis and croup. Otolaryngol Clin North Am. 2008;41(3):551-566. (Review article)
  26. Behrman RE, Kliegman RM, Jenson HB. Nelson Textbook of Pediatrics. Philadelphia, Pa: WB Saunders; 1996. (Textbook)
  27. Fleisher GR, Ludwig S. Textbook of Pediatric Emergency Medicine. Philadelphia, Pa: Wolters Kluwer/Lippincott Williams & Wilkins Health; 2010. (Textbook)
  28. Faden H. The dramatic change in the epidemiology of pediatric epiglottitis. Pediatr Emerg. 2006;22(6):443-444. (Retrospective chart review; 2 cases)
  29. Tibballs J, Watson T. Symptoms and signs differentiating croup and epiglottits. J Paediatr Child Health. 2011;47(3):77-82. (Prospective study; 203 patients)
  30. Leung AKC, Kellner JD, Johnson DW. Viral croup: a current perspective. J Pediatr Health Care. 2004;18(6)297-301. (Review article)
  31. * Westley CR, Cotton EK, Brooks JG. Nebulized racemic epinephrine by IPPB for the treatment of croup. Am J Dis Child. 1978;132(5):484-487. (Randomized controlled trial; 20 patients)
  32. Klassen TP, Feldman ME, Watters LK, et al. Nebulized budesonide for children with mild-to-moderate croup. N Engl J Med. 1994;331(5):285-289. (Randomized controlled trial; 54 patients)
  33. Bjornson CL, Johnson DW. Croup. Lancet. 2008;371(9609):329-339. (Review article)
  34. Salour M. The steeple sign. Radiology. 2000;216(2):428-429. (Case report)
  35. Currarino G, WIlliams B. Lateral inspiration and expiration radiographs of the neck in children with laryngotracheitis. Radiology. 1982;145(2):365-366. (Retrospective chart review; 100 patients)
  36. Pope, AE. The Profession of Home Making: A Condensed Home-study Course on Domestic Science; The Practical Application of the Most Recent Advances in the Arts and Sciences to the Home Industries. Chicago: American School of Home Economics, 1911. (Textbook)
  37. Greally P, Cheng K, Tanner MS, et al. Children with croup presenting with scalds. Br Med J. 1990;301(6743):113. (Case reports; 2 patients)
  38. Lavine E, Scolnik D. Lack of efficacy of humidification in the treatment of croup: why do physicians persist in using an unproven modality? CJEM. 2001;3(3):209-212. (Review article)
  39. Rosenkrans JA. Viral croup: current diagnosis and treatment. Mayo Clin Proc. 1998;73(11):1102-1107. (Review article)
  40. Moore M, Little P. Humidified air inhalation for treating croup: a systematic review and meta-analysis. Fam Prac. 2007;24(4):295-301. (Systematic review and meta-analysis of 3 studies; 135 patients)
  41. Bourchier D, Dawson KP, Fergusson DM. Humidification in viral croup: a controlled trial. Aust Paedatr J. 1984;20(4):289-291. (Randomized controlled trial; 16 children)
  42. Neto GM, Kentab O, Klassen TP, et al A randomized controlled trial of mist in the acute treatment of moderate croup. Acad Emerg Med. 2002;9(9):873-879. (Randomized controlled trial; 71 patients)
  43. Scolnik D, Coates AL, Stephens D, et al. Controlled delivery of high vs low humidity vs mist therapy for croup in emergency departments. JAMA. 2006;295(11):1274-1280. (Randomized controlled trial; 140 patients)
  44. Corkey C, Barker G, Edmonds J, et al. Radiographic tracheal diameter measurements in acute infectious croup: an objective scoring system. Crit Care Med. 1981;9(8):587-590. (Randomized controlled trial; 14 patients)
  45. Kristjansson S, Berg-Kelly K, Winso E. Inhalation of racemic adrenaline in the treatment of mild and moderately severe croup. Clinical symptom score and oxygen saturation measurements for evaluation of treatment effects. Acta Paediatrica. 1994;83(11):1156-1160. (Randomized controlled trial; 54 patients)
  46. Adair JC, Ring WH, Jordan WS, et al. Ten-year experience with IPPB in the treatment of acute laryngotracheobronchiolitis. Anest Analg. 1971;50(4):649-655. (Retrospective chart review)
  47. Fogel JM, Berg IJ, Gerber MA, et al. Racemic epinephrine in the treatment of croup: nebulization alone versus nebulization with intermittent positive pressure breathing. J Pediatr. 1982;101(6):1028-1031. (Randomized controlled trial; 14 patients)
  48. Waisman Y, Klein BL, Boenning DA, et al. Prospective randomized double-blind study comparing L-epinephrine and racemic epinephrine aerosols in the treatment of laryngotracheitis (croup). Pediatrics. 1992;89(2):302-306. (Randomized controlled trial; 28 patients)
  49. Ledwith CA, Shea LM, Mauro RD. Safety and efficacy of nebulized racemic epinephrine in conjunction with oral dexamethasone and mist in the outpatient treatment of croup. Ann Emerg Med. 1995;25(3):331-337. (Prospective interventional study; 55 patients)
  50. Zhang L, Sanguebsche L. The safety of nebulization with 3 to 5 ml of adrenaline (1:1000) in children: an evidence based review. J Pediatr (Rio J). 2005;81(3):193-197. (Systematic review; 7 trials; 238 patients)
  51. Butte MJ, Nguyen BX, Hutchison TJ, et al. Pediatric myocardial infarction after racemic epinephrine administration. Pediatrics. 1999;104(1):e9. (Case report; 1 patient)
  52. Kelly PB, Simon JE. Racemic epinephrine use in croup and disposition. Am J Emerg. 1992;10(3):181-183. (Retrospective chart review; 50 patients)
  53. Thomas LP, Friedland LR. The cost-effective use of nebulized racemic epinephrine in the treatment of croup. Am J Emerg Med. 1992;10(3):181-183. (Cross-sectional study; 23 hospitals)
  54. Super DM, Cartelli NA, Brooks LJ, et al. A prospective randomized double-blind study to evaluate the effect of dexamethasone in acute laryngotracheitis. J Pediatr. 1989;115(2):323-329. (Randomized controlled trial; 29 patients)
  55. Bjornson CL, Klassen TP, Williamson J, et al. A randomized controlled trial of a single of oral dexamethasone for mild croup. N Engl J Med. 2004;351(13):1306-1313. (Randomized controlled trial; 720 patients)
  56. Geelhoed CC, Macdonald WBS. Oral and inhaled steroids in croup: a randomized, placebo-controlled trial. Pediatr Pulmonol. 1995;20(6):355-361. (Randomized controlled trial; 80 patients)
  57. Klassen TP, Craig WR, Moher D, et al. Nebulized budesonide and oral dexamethasone for treatment of croup: a randomized controlled trial. JAMA, 1998;21(6):359-362. (Randomized controlled trial; 198 patients)
  58. Fifoot A, Ting JYS. Comparison between single-dose oral prednisolone and oral dexamethasone in the treatment of croup: a randomized double-blinded clinical trial. Emerg Med Australas. 2007;19(1):51-58. (Randomized controlled trial; 99 patients)
  59. Luria JW, Gonzalez-del-Rey JA, DiGiulio GA, et al. Effectiveness of oral or nebulized dexamethasone for children with mild croup. Pediatr Adolesc Med. 2001;155(12):1340-1345. (Randomized controlled trial; 264 patients)
  60. Johnson DW, Jacobson S, Edney PC, et al. A comparison of nebulized budesonide, intramuscular dexamethasone, and placebo for moderately severe croup. N Engl J Med. 1998;339(8):498-503. (Randomized controlled trial; 144 patients)
  61. Geelhoed, GC. Budesonide offers no advantage when added to oral dexamethasone in the treatment of croup. Ped Emerg Care. 2005;21(6):359-362. (Randomized controlled trial; 72 patients)
  62. Geelhoed, GC. Oral dexamethasone in the treatment of croup: 0.15 mg/kg versus 0.3 mg/kg versus 0.6 mg/kg. Ped Pulmonol. 1995;20(6):362-368. (Randomized controlled trial; 120 patients)
  63. Dobrovoljac M, Geelhoed GC. 27 years of croup: an update highlighting the effectiveness of 0.15 mg/kg of dexamethasone. Emerg Med Austral. 2009;21(4):309-314. (Retrospective descriptive report)
  64. Parker C. “ToPDog” is in progress. Emerg Med J. 2010;27(12):961. (Letter)
  65. A comparison of oral prednisolone and oral dexamethasone in children with croup: a prospective, randomised, double blinded multicentre trial, Australian New Zealand Clinical Trials Registry, ACTRN12609000290291. (Randomized controlled trial, unpublished data)
  66. Barach AL. The therapeutic use of helium. JAMA. 1936;107:1273-1280. (Observational study)
  67. Beckmann KR, Brueggemann WM. Heliox treatment of severe croup. Am J Emerg Med. 2000;18(6):735-736. (Case report)
  68. DiCecco RJ, Rega PP. The application of heliox in the management of croup by an air ambulance service. Air Med J. 2000;23(2):33-35. (Case report)
  69. Smith SW Biros M. Relief of imminent respiratory failure from upper airway obstruction by use of helium-oxygen: a case series and brief report. Acad Emerg Med. 1999; 6(9):953-956. (Case series; 5 patients)
  70. Terregino C, Nairn S, Chansky M, et al. The effect of heliox on croup: a pilot study. Acad Emerg Med. 1998;5(11):1130- 1133. (Randomized trial; 15 patients)
  71. Weber JE, Chudnofsky CR, Younger JG, et al. A randomized comparison of helium-oxygen mixture (heliox) and racemic epinephrine for the treatment of moderate to severe croup. Pediatrics. 2001;107(6):E96. (Randomized controlled trial; 33 patients)
  72. ISRCTN82240782. Children receiving heliox inhalation in croup: a randomized controlled trial (CHIC). Current Controlled Trials. (Unpublished data)
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  76. Boudewyns A, Claes J, Van de Heyning P. An approach to stridor in infants and children. Eur J Pediatr. 2010;169(2):135- 141. (Review article)
  77. Walker, RWM. Management of the difficult airway in children. J R Soc Med. 2001;94(7):341-344. (Review article)
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  79. Hoa M, Kingsley EL, Coticchia JM. Correlating the clinical course of recurrent croup with endoscopic findings: a retrospective observational study. Ann Otol Rhinol Layryngol. 2008;117(6)464-469. (Observational study; 47 patients)
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