Acc

epte

d A

rtic

le

This article has been accepted for publication and undergone full peer review but has not been through the copyediting, typesetting, pagination and proofreading process, which may lead to differences between this version and the Version of Record. Please cite this article as doi: 10.1111/apa.12398 This article is protected by copyright. All rights reserved.

Received Date : 19-Jul-2013 Revised Date : 13-Aug-2013 Accepted Date : 19-Aug-2013 Article type : Letter Letter to the Editor

Using ibuprofen to treat croup in six children presenting to an

emergency unit

Sebastiano A.G. Lava, Mario G. Bianchetti, Giacomo D. Simonetti*

Department of pediatrics, San Giovanni Hospital, Bellinzona, and University of Berne, Switzerland.

* Present appointment: Pediatric Nephrology, University Children’s Hospital Berne and University of Berne,

Switzerland.

Corresponding author: Mario G. Bianchetti, MD, Department of Pediatrics, San Giovanni Hospital, 6500

Bellinzona, Switzerland (Email: mario.bianchetti@pediatrician.ch)

Telephone: +41 811 86 68

Fax: + 41 811 811 80 26

Between January and April 2013, we performed a simple explorative study with oral ibuprofen 8 mg/kg in

six consecutive children - four boys and two girls aged from one to seven-years-of-age (median four years)

- who presented to our emergency unit with a rather mild attack of croup. This letter reports our initial

experiences of this treatment.

Croup is characterised by inspiratory stridor, barking cough, and hoarseness that typically occur in

children between one and six-years-of-age. It results from inflammation in the larynx and subglottic airway,

which is mostly caused by a parainfluenza virus (1).

Acc

epte

d A

rtic

le

This article is protected by copyright. All rights reserved.

Although croup is usually a mild and self-limited illness, it causes substantial upper airway obstruction

and difficulty in breathing and, very rarely, death, can occur. The management of croup has changed

notably since the 1990s. Clinical evidence largely supports the efficacy of nebulised or oral corticosteroids

in mild, moderate and severe cases and nebulized epinephrine in moderate and severe cases as the

cornerstones of therapy. Humidified air is also routinely administered to children with croup, but available

data do not support a clinically relevant benefit of humidified air for this condition (1).

Some countries, including Switzerland (2), and many websites frequently recommended non-steroidal

anti-inflammatory drugs, particularly ibuprofen, to alleviate pain and reduce swelling in croup. Surprisingly,

were unable to identify any research evidence to determine whether it is appropriate to give ibuprofen to a

child with croup.

The six children who presented to our emergency unit with mild croup were managed exclusively with

humidified air and a single dose of a palatable syrup containing ibuprofen. The Westley croup score, which

has been extensively studied and validated, was assessed immediately before and 60 minutes after taking

ibuprofen(3). As shown in Figure 1, the Westley croup score decreased in all children following the

administration of ibuprofen (P<0.05; two-tailed Wilcoxon matched paired signed rank test).

These preliminary observations suggest that the non-steroidal anti-inflammatory agent ibuprofen might be a

simple, rapid-acting, well-tolerated and cheap treatment strategy for children with croup. The hypothesis

needs to be demonstrated in a well-designed, randomised, placebo-controlled trial.

References

1 Fitzgerald DA. The assessment and management of croup. Paediatr Respir Rev 2006; 7: 73-81.

2 Pfenninger J, Rossi E. Diagnosis and management of the croup syndrome. Schweiz Rundsch Med Prax

1982; 71: 468-72.

3 Westley CR, Cotton EK, Brooks JG. Nebulized racemic epinephrine by IPPB for the treatment of croup: a

double-blind study. Am J Dis Child 1978; 132: 484-7.

Acc

epte

d A

rtic

le

This article is protected by copyright. All rights reserved.

Figure 1 - Legend

Westley croup score just before, and 60 minutes after, administration of ibuprofen syrup 8 mg/kg body

weight in six children (four boys and two girls aged from one to seven, median four years). A score of 1–2

indicates mild, a score of 3–8 moderate and a score of >8 severe croup.

Before

3

AfterIbuprofen

2

1

0Wes

tley

Cro

up

Sco

re

♂♀

P<0.05

Figure 1

Westley Croup ScoreBefore and After

Ibuprofen 8 mg/kg body weight