Welcome to this edition of "Things I Do but Should I?", where we dive into common medical practices that we’ve all been taught, but that may not be as evidence-based as we think. Here, we’ll tackle supportive care advice for one of the most common pediatric respiratory conditions: croup.
Supporting Croup: What’s Really Effective?
In daily practice, much of the advice we give patients regarding supportive care is handed down from generations of providers, often without clear evidence to back it up. This is especially true when it comes to treating croup. We’ve all heard recommendations for steam from a hot shower or taking a child into the cold night air, but what does the evidence actually say? By the end of this post, you might find yourself rethinking what to tell parents when it comes to managing croup symptoms at home.
What Is Croup?
First, let’s get grounded in what we mean by croup. Croup, or acute viral laryngotracheitis, presents as a viral infection leading to subglottic airway narrowing. The hallmark symptoms include a barking, seal-like cough, often accompanied by hoarseness and inspiratory stridor. Children with croup frequently experience a sudden onset of symptoms, typically at night, and though it can seem alarming, the condition generally resolves on its own within 48 hours.
Diagnosing Croup
Thankfully, diagnosing croup is straightforward. The combination of a barking cough, inspiratory stridor, and hoarseness leads to a clinical diagnosis. While you might occasionally see an X-ray showing the "steeple sign" caused by subglottic narrowing, an x-ray is rarely needed. Croup severity can also be assessed using the Westley Croup Severity (WCS) score, which evaluates a child’s consciousness, cyanosis, stridor, air entry, and severity of retractions.
Standard Treatment of Croup
The go-to treatment for croup, regardless of severity, is a single dose of oral dexamethasone. For moderate-to-severe cases, nebulized epinephrine may also be used, but dexamethasone remains the foundation of therapy. In addition to dexamethasone, many of us have been taught to recommend humidified air or exposure to cold air for symptomatic relief. But is there any evidence that these practices are beneficial?
Mist: Popular but Not Proven
One of the most common recommendations is for children with croup to breathe in humidified air, often by sitting in a steamy bathroom. I have recommended this to many parents over the years. However, when we look at the data, this practice doesn’t hold up.
Multiple studies, including a 2002 randomized trial and a 2007 systematic review, found no meaningful benefit from humidified air for croup treatment. Children with mild-to-moderate croup did not experience improvements in their croup scores when exposed to humidified air compared to no humidification at all.
Conclusion: Despite its long-standing popularity, the evidence doesn’t support mist as an effective treatment for croup.
Cold Air: A Cool Option?
Cold air, on the other hand, has been anecdotally recommended for decades. Until recently, we didn’t have strong evidence to back this up, but a 2023 study published in Pediatrics has shed some light on this practice.
In this study, 118 children with croup were randomized to spend 30 minutes either outdoors in cold air (<50°F) or indoors at ambient room temperature after receiving a dose of oral dexamethasone. The study found that a significantly higher proportion of children in the cold-air group showed clinical improvement (defined as a drop of at least two points on the WCS score) compared to those who stayed indoors.
Interestingly, the benefit was most apparent in children with moderate croup. By 60 minutes post-intervention, however, the difference between groups had evened out, likely due to the effects of the dexamethasone.
Conclusion: Cold air seems to offer a short-term benefit, particularly in moderate cases. This could be a simple, low-risk intervention to recommend while en route to a healthcare setting.
What Should We Tell Parents?
Based on the current evidence, taking a child outside into the cold air for a limited time might provide some short-term relief for croup symptoms. This approach is low-risk and could be helpful while families seek medical care. On the other hand, the traditional advice to use humidified air doesn’t seem to hold up under scrutiny and can likely be dropped from our supportive care toolkit.
So, where do we stand after reviewing the data? Personally, I’ll be moving away from recommending humidified air and focusing more on advising parents to try cold air as a short-term solution. It’s a safe, evidence-supported option, especially for children with moderate croup. We all know how challenging it is to update deeply ingrained practices, but evidence-based guidance is always worth the effort.
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