Heliox for Croup in Children

This week, as part of the Child Health Emergency Medicine Social Media Campaign, we are highlighting a Cochrane summary on heliox for the treatment of croup in children. This review was selected for the TREKK Evidence Repository on croup.

Key Messages:

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Related TREKK Resources:

Cochrane Summary:

Helium-oxygen (heliox) treatment for croup in children

Croup is an acute illness commonly seen in children up to six years of age but mostly by the age of two. It is triggered by viral infections causing upper airway obstruction with varying degrees of respiratory distress. Mostly, it is mild and transient and resolves with supportive care. Croup is characterised by a barking cough, hoarseness, varying degrees of inspiratory stridor (abnormal breathing sound) and chest wall retractions and is usually preceded by one to three days of upper respiratory tract infection symptoms. The peak croup seasons are autumn and winter but can occur at any time.

Corticosteroids are an accepted treatment for moderate to severe croup, supplemented in more severe cases by nebulised epinephrine and oxygen. Epinephrine is often effective and safe but can have undesired effects (such as increased heart rate and anxiety). Corticosteroids improve croup symptoms but it takes time for their full effect to be achieved. In the meantime the child remains at risk of deterioration. This may rarely result in the development of respiratory failure, which may require emergency intubation and ventilation. Therefore, finding a safe and effective treatment to bridge the gap between the administration and effectiveness of the corticosteroids is important for clinical practice.

Some studies have shown a benefit of using heliox in children with croup. Heliox, a gas with lower density than air or oxygen, is believed to reduce the resistance to gas flow in narrowed upper airways, potentially improving symptoms and signs of respiratory distress. This review found three randomised controlled trials (RCTs) assessing the effect of heliox in 91 children with croup. Heliox did not appear to be more effective than administration of 30% oxygen in children with mild croup. In children with moderate to severe croup who had been administered oral or intramuscular corticosteroids, heliox appeared to be at least as effective as continuous 100% oxygen with one to two doses of nebulised racaemic epinephrine (adrenaline as a fine spray) in one study. It was slightly more effective than no treatment in another study. There were no adverse effects or outcomes reported. The included trials were small and had a number of methodological limitations. Further methodologically well-designed RCTs with more participants are needed to further assess the role of heliox in managing children with moderate to severe croup. The evidence is current to November 2013.

Authors’ Conclusions:

There is some evidence to suggest a short-term benefit of heliox inhalation in children with moderate to severe croup who have been administered oral or intramuscular dexamethasone. In one study, the benefit appeared to be similar to a combination of 100% oxygen with nebulised epinephrine. In another study there was a slight change in croup scores between heliox and controls, with unclear clinical significance. In another study in mild croup, the benefit of humidified heliox was equivalent to that of 30% humidified oxygen, suggesting that heliox is not indicated in this group of patients provided that 30% oxygen is available. Adequately powered RCTs comparing heliox with standard treatments are needed to further assess the role of heliox in children with moderate to severe croup.

Check Out the Full Cochrane Systematic Review Below:

Moraa, I., Sturman, N., McGuire, T., van Driel, M.L. (2012). Heliox for croup in children. Cochrane Database Syst Rev, 12, CD006822. doi: 10.1002/14651858.CD006822.pub4

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This post is part of a weekly blog series highlighting pediatric emergency medicine (PEM) focused Cochrane summaries and other key resources selected by TREKK.

Published by arrangement with John Wiley & Sons.

Interventions for Treating Femoral Shaft Fractures in Children and Adolescents

This week, as part of the Child Health Emergency Medicine Social Media Campaign, we are highlighting a Cochrane summary on interventions for treating femoral shaft fractures in children and adolescents. This review was selected for the TREKK Evidence Repository on fractures.

Key Messages:

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Related TREKK Resources:

Cochrane Summary:

Different methods of treating fractures of the shaft of the thigh bone in children and adolescents

Although uncommon, fractures of the femoral shaft (thigh bone) in children may require prolonged treatment in hospital and sometimes surgery. This can cause significant discomfort and can disrupt the lives of the children and their familles. This review compared different methods of treating these fractures. Surgical treatment comprises different methods of fixing the broken bones, such as internally-placed nails, or pins incorporated into an external frame (external fixation). Non-surgical or conservative treatment usually involves different types of plaster casts with or without traction (where a pulling force is applied to the leg).

We searched for studies in the medical literature until August 2013. The review includes 10 randomised or quasi-randomised controlled trials that recruited 527 children. Four trials compared different surgical versus non-surgical treatments; three compared different methods of non-surgical treatment and three compared different methods of surgical treatment. Generally we are unsure about the results of these trials because some were at risk of bias, some results were contradictory and usually there was too little evidence to rule out chance findings. Most trials failed to report on self-assessed function or when children resumed their usual activities.

Comparing surgical versus non-surgical treatment

Low quality evidence (one trial, 101 children) showed children had similar function at two years after having surgery, involving external fixation, compared with those treated with a plaster cast. The other three trials did not report this outcome. There was moderate quality evidence (four trials, 264 children, aged 4 to 12 years, followed up for 3 to 24 months) that surgery reduced the risk of malunion (the leg is deformed) compared with non-surgical treatment. However, low quality evidence (four trials) indicated that there were more serious adverse events such as infections after surgery. There was low quality evidence (one trial, 101 children) of similar satisfaction levels in children and parents with surgery involving external fixation and plaster cast only. However, there was low quality evidence (one trial, 46 children) that more parents were satisfied with surgery involving an internal nail than with traction followed by a cast and that surgery reduced the time taken off from school.

Comparing various non-surgical treatments

Very low quality evidence means that we are very unsure if the rates of malunion differ or not between children treated with immediate plaster casts versus with traction followed by plaster cast (one trial, 42 children), or between children treated with traction followed by either a functional orthosis (a brace or cast that allows some movement) or a cast (one trial, 43 children). We are very unsure if either function or serious adverse events differ between young children (aged two to seven years) immobilised in single-leg versus double-leg casts (one trial, 52 children). However, single-leg casts appear to be easier to manage by parents and more comfortable for the child.

Comparing various surgical treatments

Very low quality evidence means that we are very unsure if the rates of malunion, serious adverse events, time to return to school or parental satisfaction actually differ in children whose fractures were fixed using internal nails or external fixation (one trial, 19 children). The same applies to the rates of serious adverse events and time to resume full weight-bearing in children treated with dynamic (less rigid) versus static external fixation (one trial, 52 children). Very low quality evidence (one trial, 47 children) means that we do not know if malunion, serious adverse events and time to resume weight-bearing actually differ between intramedullary nailing versus submuscular plating. However, there could be more difficulties in plate removal subsequently.

Conclusions

This review found insufficient evidence to determine if long-term function differs between surgical and conservative treatment of thigh bone fractures in children aged 4 to 12 years. It found surgery resulted in lower rates of malunion but increased the risk of serious adverse events, such as infections. It found internal nailing may speed up recovery.

The review found there was insufficient evidence from comparisons of different methods of non-surgical treatment to clearly show that any type of non-surgical treatment is better than any other. The same conclusion applies to comparisons of different methods of surgical treatment.

Authors’ Conclusions:

There is insufficient evidence to determine if long-term function differs between surgical and conservative treatment. Surgery results in lower rates of malunion in children aged 4 to 12 years, but may increase the risk of serious adverse events. Elastic stable intramedullary nailing may reduce recovery time.

There is insufficient evidence from comparisons of different methods of conservative treatment or of different methods of surgical treatment to draw conclusions on the relative effects of the treatments compared in the included trials.

Check Out the Full Cochrane Systematic Review Below:

Madhuri, V., Dutt, V., Gahukamble, A.D., Tharyan, P. (2014). Interventions for treating femoral shaft fractures in children and adolescents. Cochrane Database Syst Rev, 7, CD009076. doi: 10.1002/14651858.CD009076.pub2

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This post is part of a weekly blog series highlighting pediatric emergency medicine (PEM) focused Cochrane summaries and other key resources selected by TREKK.

Published by arrangement with John Wiley & Sons.