Pediatrics – PICO #2

Brief description of patient problem/setting (summarize the case very briefly)

30-month-old F, accompanied by her mother, comes in to the pediatrics emergency room c/o a cough that has not gone away x 2 days. You hear a bark-like cough, but the child does not seem to be very symptomatic.

Search Question: Clearly state the question (including outcomes or criteria to be tracked)

In children with mildly symptomatic croup is oral dexamethasone still the go-to steroid to administer verses oral prednisolone in reducing the duration of a child’s cough and illness trajectory?

Question Type: What kind of question is this? (boxes now checkable in Word)

☐Prevalence                             ☐Screening                  ☐Diagnosis

☐Prognosis                              ☒Treatment                 ☐Harms

Assuming that the highest level of evidence to answer your question will be meta-analysis or systematic review, what other types of study might you include if these are not available (or if there is a much more current study of another type)? Please explain your choices.

– If meta-analysis or systematic review are not available, randomized controlled clinical trials will also offer great supporting evidence as they are carefully planned experiments, reduce the potential for bias, and allow for comparison between intervention and control groups.

– Cohort studies could also be used since they allow to follow the patients who have already received a particular treatment forward over time. This is not as reliable as randomized controlled clinical trials since patients might differ in ways other than in the variable that is being observed.

PICO search terms:

ChildrenPrednisoloneDexamethasoneReducing Illness
Pediatric patients  Faster Symptom relief
Croup  Decreased cough

Search tools and strategy used:

Please indicate what data bases/tools you used, provide a list of the terms you searched together in each tool, and how many articles were returned using those terms and filters.
Explain how you narrow your choices to the few selected articles.

Results found:

TRIP Database

  • Croup AND Steroids – 12
  • Croup AND Prednisolone AND Dexamethasone – 7


  • Comparison between single-dose oral prednisolone and oral dexamethasone – 20


  • Pediatrics AND Prednisolone AND Dexamethasone (in the last 10 years) – 139
  • Croup AND Prednisolone AND Dexamethasone (in the last 10 years) – 11

There were not many articles in regards to the efficacy between using prednisolone versus dexamethasone in treating croup (laryngotracheobronchitis). The few articles that did were very granular in their research and reporting, which was I thankful for, and many articles overlapped when I went through the different search engines. There was a research article that all these articles referred to back in 2007 that looked at the differences between both steroids, but I thought it was too old to include below.

Identify at least 3 articles (or other appropriate reputable sources) that answer your specific question with the highest available level of evidence (you will probably need to look at more than 3 articles to get the 3 most focused and highest-level articles to address your question). Please make sure that they are Medline indexed.

Please post the citation and abstract for each article (to include the journal and authors’ names and date) and say why you chose it.
Please also note what kind of article it is (e.g. meta-analysis, cohort study, or independent blind comparison with gold standard of diagnosis, etc.).

At the bottom of each abstract, please comment on what your key points are from this article (including any points or concepts included in the article, but not present in the abstract – i.e. make the concepts understandable to the reader)

Please note that if the evidence is not in the abstract, you must clearly summarize the evidence in your posting.

Citation: Garbutt, J. M., Conlon, B., Sterkel, R., Baty, J., Schechtman, K. B., Mandrell, K., Leege, E., Gentry, S., & Stunk, R. C. (2013). The Comparative Effectiveness of Prednisolone and Dexamethasone for Children With Croup: A Community-Based Randomized Trial. Clinical Pediatrics, 52(11), 1014–1021.  
Type of article: Community-Based Randomized Trial  
Abstract Background—Although common practice, evidence to support treatment of croup with prednisolone is scant.   Methods—We conducted a community-based randomized trial to compare the effectiveness of prednisolone (2mg/kg/day for 3 days, n=41) versus one dose of dexamethasone (0.6 mg/kg) and two doses of placebo (n=46). Participants were children 1–8 years of age with croup symptoms ≤ 48hr, categorized as mild (42%) or moderate (58%).   Results—There were no differences for those treated with dexamethasone or prednisolone for additional healthcare for croup (2% vs. 7%, p=0.34), duration of croup symptoms (2.8 days vs. 2.2 days, p=0.63), non-barky cough (6.1 days vs. 5.9 days, p=0.81), nights with disturbed sleep for the parent (0.68 nights vs. 1.21 nights, p=0.55), and days with stress (1.39 days vs. 1.56 days, p=0.51). Conclusion—There were no detected differences in outcomes between the two croup treatments for either child or parent.  
Key Points: The research is comprised from a community randomized control trial with eighty-seven children studied over ten different pediatric practicesThe subjects were either diagnosed with mild or moderate croup at the time of their office visit46 children were to receive one oral dose dexamethasone and 41 were to receive a 3-day course of prednisoloneCroup symptoms persisted for an average of 2.8 days for those on dexamethasone as compared with 2.2 days for the group that was on prednisoloneThe conclusion was that there was no difference in outcomes for the children with mild or moderate croup symptoms whether getting one oral dose of dexamethasone or a 3-day course of prednisolone  
Why I chose it: I chose this article because it was one of the first studies to investigate the differences between treating with dexamethasone and prednisolone in the context of treating croup. Having information between almost a dozen different pediatric offices across the greater St. Louis, MO area was very appreciated. Unfortunately, I wish there was a bigger sample size, which would have given more results, but I appreciate the authors for trying to look for a treatment plan that was not part of the norm.  
Citation: Asif, A., Tayyab, A., Qazi, S., Zulfqar, R., Hussain, I., & Mumtaz, H. (2023). Comparison between single-dose oral prednisolone and oral dexamethasone in the treatment of croup: a randomized-controlled trial. Annals of Medicine and Surgery, 85(5), 1379–1384.
Type of article: Randomized Controlled Trial  
Abstract: Croup is a common respiratory illness in children, accounting for 15% of annual clinic and emergency department visits for pediatric respiratory tract infections. We aimed to compare single-dose oral prednisolone with single-dose oral dexamethasone in the treatment of croup in terms of mean change in the Westley Croup Score.   Setting: Emergency Department of Children Hospital. Duration: Six months from December 2017 to June 2022. Design: Randomized-controlled trial. Subjects and methods: A total of 226 children with Westley Croup Score 2 or more were included in this study. Patients were randomized into two groups, 113 patients received a single dose of 0.15 mg/kg of oral dexamethasone, while 113 patients received a single dose of 1 mg/kg of oral prednisolone. Croup score and other clinical observations were repeated at 4 h and recorded in the questionnaire. Results: The average age of the patients was 2.88±1.17 years. There were 129 (57.1%) males and 97 (42.9%) females. At 4 h, a significant reduction in mean Westley Croup Score was observed in group dexamethasone as compared with group prednisolone (P=0.0005). Conclusions: Our trial demonstrated that oral dexamethasone at a dose of 0.15 mg/kg is effective in reducing the total croup score but there were no statistical differences in respiratory rate, pulse rate, and oxygen saturation between groups. Future studies are required to determine if these treatments differ in efficacy for severe croup and whether there is a role for multiple-dose corticosteroid therapy in some patients.  
Key Points: As compared to the study above this study had almost three times more subjects to gather information from. 226 children were treated in an emergency room setting (as opposed to various pediatric offices)113 children were given one oral dose of dexamethasone and the other 113 were given one oral dose of prednisoloneThe conclusions mirrored those of the last study. Both dexamethasone and prednisolone were both effective in reducing symptomatology of croup in both groups of children. Even though dexamethasone reduced the total croup score system more effectively, there were no differences in either treatment outcome.  
Why I chose it: I chose this article because it was a larger randomized control group that was situated in an emergency room of a hospital where subjects could be tracked more efficiently. Additionally, each control group was split evenly, unlike the other study, and each group was administered one dose of steroids. This article also touched on the availability of medications and I thought it was very apt to include because knowing if one medication has the same efficacy as another that was more readily available to a population is tantamount in treating that patient population more effectively than not.  
Citation: Parker CM, Cooper MN. Prednisolone Versus Dexamethasone for Croup: a Randomized Controlled Trial. Pediatrics. 2019;144(3).
Type of article: Randomized Control Trial  
Abstract 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.  
Key Points: This study takes place in Perth, Australia, but the number of participants in the study could not be overlookedThis RCT took place in both a pediatric emergency department and an urban district emergency department1,231 children were enrolled randomly to receive either dexamethasone (0.6mg/kg), low dose dexamethasone (0.15mg/kg), or prednisolone (1mg/kg).The Westly Croup score was measured one hour after treatment and at the end of 7 days. All three treatment options had the same impact on the patient’s treatment outcome both one hour after treating and a week later.  
Why I chose it: I chose this article because of the vast number of participants that were included across two separate emergency rooms. There was also the other variant of looking at whether a lower dose of dexamethasone was as efficacious as a standard dose of dexamethasone, which this study showed that it was. Ultimately, this study showed there was no significant difference between the three control groups at one hour and emergency department readmittance a week later.  

What is the clinical “bottom line” derived from these articles in answer to your question?

Dexamethasone is generally the go-to steroid to treat mild to moderate croup symptoms. This PICO set out to find if an alternative steroid, prednisolone, was an adequate substitute. Both steroids are taken orally, with prednisolone being milder and more palpable in taste than dexamethasone. Prednisolone needed to be dosed one or two times more than dexamethasone, but that did not change how effective the treatment was for croup. I also found that in certain parts of the world, prednisolone was easier to acquire than dexamethasone. The bottom line is that both dexamethasone (whether it be a low dose or a standard dose) and prednisolone treat the symptoms of croup appropriately and either can be given to treat a pediatric patient.


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