Key messages

• The use of systemic corticosteroids in children with acute obstructive laryngitis increases the number of patients with clinical improvement at 12 hours and reduces the risk of readmission.
• Adverse effects associated with a single dose in the treatment of acute obstructive laryngitis would not be associated to adverse effects.

What is the evidence.
See evidence matrix  in Epistemonikos later

We found six systematic reviews [4],[5],[6],[7],[8],[9] including twenty-five randomized controlled trials [10], [11],[12],[13],[14],[15],[16],[17],[18],[19],[20],[21], [22],[23],[24],[25],[26],[27],[28],[29],[30],[31],[32], [33],[34] evaluating the use of corticosteroids compared to placebo.

What types of patients were included*

Eight trials included patients who consulted in an emergency department [12],[15],[16],[19],[21],[22],[25], [31] and sixteen included patients in the hospital setting [10],[11],[13],[14],[17],[18],[20],[23],[24],[26],[28], [29],[30],[33],[34]. One trial considered a group evaluated in emergency services that was then admitted to the hospital [32].The age range ranged from 3 months to 12 years.

Three trials included patients with mild laryngitis [12], [16],[31], three with moderate laryngitis [21],[22],[25] and one mild to moderate [15]. Eighteen trials did not classify the severity of laryngitis [10],[11],[13],[14],[17], [18],[19],[20],[23],[24],[26],[27],[28],[29],[30],[32],
[33],[34].

What types of interventions were included*

Seventeen trials considered only the use of systemic corticosteroids (oral, nasogastric, intravenous, subcutaneous and intramuscular) [12],[13],[14],[17],[18],
[19],[20],[23],[24],[25],[26],[28],[29],[30],[31],[33],[34] five evaluated inhaled corticosteroids [10],[11],[15], [21] , [27] and three considered both systemic corticosteroids and inhaled [16],[22],[32].

The corticosteroids used were prednisone, dexamethasone, methylprednisolone, prednisolone and budesonide.

The dosages used had great variation between the different trials. From the eighteen trials that considered the use of systemic corticosteroids, fourteen used dexamethasone in different single doses (0.6 mg/kg [12], [16],[17],[22],[25],[32],[33], 0.15 mg/kg [31], 0.3 mg/kg [19], 0.4 mg/kg [29], 0.5 mg/kg [24], between 4 and 12 mg total [20],[23],[28]). Two trials used 4 mg/kg methylprednisolone once or twice [14],[26] (equivalent to 0.8 mg/kg dexamethasone dose). Two trials used prednisolone, one at a dose of 2 mg/kg up to 24 hours post-extubation [13] (equivalent to 0.3 mg/kg dexamethasone), and another 2.5 mg at 6 hours without specifying time of treatment [18]. One trial used prednisone 2.5 to 5 mg three doses in one day (equivalent to 0.4 to 0.8 mg dexamethasone dose) [34] and one trial used dexamethasone used 0.04 mg/kg/day in 4 doses [30]. The rest of the trials used the inhalation route with budesonide from 1 to 4 mg per dose up to 4 doses, and nebulized dexamethasone from 10 to 20 mg.

What types of outcomes
were measured

The trials measured multiple outcomes, however, the different systematic reviews grouped them as follows:

• Croup score (change from 0 to 6, 12, 24 hours) according to score (Westley score and non-Westley score)
• Westley score (change from 0 to 6, 12 and 24 hours) according to inpatient or outpatient
• Westley score (change from 0 to 6, 12 and 24 hours) according to corticosteroid (budesonide, dexamethasone, fluticasone)
• Readmissions/reconsultations according to inpatient or outpatient
• Readmissions/reconsultations according to corticosteroid (budesonide, dexamethasone)
• Readmissions/reconsultations according to croup severity
• Length of stay according to inpatient or outpatient
• Clinical improvement at 6, 12 and 24 hours according to inpatient or outpatient
• Additional treatments (intubation/tracheostomy, use of antibiotics, supplemental corticosteroids, epinephrine and mist tent)

To whom this evidence does and does not apply

• The evidence presented in this summary is applicable to patients with mild, moderate or severe laryngitis.
• Does not apply to a different age group than children under 13 years of age.
• None of the trials included patients in the outpatient setting, however, in the absence of direct evidence, it is reasonable to extrapolate the information presented in this summary to this context.

• It was decided to evaluate the outcomes of readmission/reconsultation and clinical improvement, because they are the most relevant outcomes for decision-making about the use of corticosteroids in laryngitis.
• In addition, the outcome intubation/tracheostomy rate was considered due to its clinical relevance in laryngitis.
• This selection is based on the opinion of the authors of the summary, but in general it agrees with the outcomes mentioned by systematic reviews.
• Data on adverse effects of single dose corticosteroids were not presented in the summary of findings table, given the existing evidence on their safety [4].

• The benefits are of great magnitude, there is certainty about them, and the adverse effects are minimal. Therefore, the benefit/risk balance is very favorable to the intervention.

• It is a low cost intervention, and the benefits are important, so the balance between cost and benefits is very favorable.

• Practically all patients and clinicians should be inclined to use this intervention with the evidence presented in this summary.
• Due to the wide knowledge about the adverse effects of chronic use of corticosteroids, there may be resistance to the use of this treatment by parents or caregivers, which makes it necessary to explain the evidence on the safety of their use in this context.

Differences between this summary and other sources

• The conclusions of this summary are consistent with the identified reviews, which report that both systemic and inhalatory corticosteroids would be effective in the treatment of laryngitis. The magnitude of the effect on all outcomes was greater in this summary than in the main systematic review [4], which could be explained by the inclusion of only the trials that evaluated systemic corticosteroids.
• This summary is consistent with the recommendations presented in the main guidelines on laryngitis in pediatrics [2],[3]. 

• The probability that future studies change the conclusions of this summary is low, due to the certainty of the existing evidence.