Table.
GRADE Evaluation of interventions for Croup.
| Important outcomes | Need for additional medical attention/admission to hospital , Symptom severity | ||||||||
| Studies (Participants) | Outcome | Comparison | Type of evidence | Quality | Consistency | Directness | Effect size | GRADE | Comment |
| What are the effects of treatments (dexamethasone or humidification) in children with mild croup? | |||||||||
| 1 (720) | Symptom severity | Oral dexamethasone versus placebo | 4 | –1 | 0 | 0 | 0 | Moderate | Quality point deducted for incomplete reporting of results |
| 2 (820) | Need for additional medical attention/admission to hospital | Oral dexamethasone versus placebo | 4 | 0 | 0 | 0 | 0 | High | |
| What are the effects of treatments in children with moderate to severe croup? | |||||||||
| 6 (287) | Symptom severity | Nebulised budesonide versus placebo | 4 | 0 | 0 | –1 | 0 | Moderate | Directness point deducted for inclusion of children with mild croup |
| 4 (228) | Need for additional medical attention/admission to hospital | Nebulised budesonide versus placebo | 4 | 0 | 0 | –2 | +1 | Moderate | Directness points deducted for inclusion of children with mild croup and composite outcome (visits and admissions); effect size point added for RR <0.5 |
| 5 (215) | Symptom severity | Intramuscular or oral dexamethasone versus placebo | 4 | –1 | 0 | 0 | 0 | Moderate | Quality point deducted for incomplete reporting of results |
| 2 (178) | Symptom severity | Intramuscular dexamethasone versus nebulised budesonide | 4 | –2 | 0 | 0 | 0 | Low | Quality points deducted for sparse data and for flaws with blinding |
| 2 (194) | Need for additional medical attention/admission to hospital | Intramuscular dexamethasone versus nebulised budesonide | 4 | –3 | 0 | 0 | 0 | Very low | Quality points deducted for sparse data, for flaws with blinding, and use of co-intervention |
| 1 (134) | Symptom severity | Oral dexamethasone versus nebulised budesonide | 4 | –1 | 0 | 0 | 0 | Moderate | Quality point deducted for sparse data |
| 2 (183) | Need for additional medical attention/admission to hospital | Oral dexamethasone versus nebulised budesonide | 4 | –1 | 0 | 0 | 0 | Moderate | Quality point deducted for sparse data |
| 2 (186) | Symptom severity | Oral dexamethasone versus oral prednisolone | 4 | –2 | 0 | –1 | 0 | Very low | Quality points deducted for sparse data and incomplete reporting of results; directness point deducted for inclusion of children with mild croup |
| 3 (306) | Need for additional medical attention/admission to hospital | Oral dexamethasone versus oral prednisolone | 4 | –1 | –1 | –1 | 0 | Very low | Quality point deducted for incomplete reporting of results; consistency point deducted for conflicting results; directness point deducted for inclusion of children with mild croup |
| 1 (277) | Symptom severity | Intramuscular versus oral dexamethasone | 4 | –1 | 0 | 0 | 0 | Moderate | Quality point deducted for flaws with blinding |
| 2 (372) | Need for additional medical attention/admission to hospital | Intramuscular versus oral dexamethasone | 4 | –1 | 0 | –1 | 0 | Low | Quality point deducted for flaws with blinding; directness point deducted for inclusion of children with mild croup |
| 3 (189) | Symptom severity | Higher-dose dexamethasone versus lower-dose dexamethasone | 4 | –1 | 0 | 0 | 0 | Moderate | Quality point deducted for sparse data |
| 3 (190) | Need for additional medical attention/admission to hospital | Higher-dose dexamethasone versus lower-dose dexamethasone | 4 | –1 | 0 | –1 | 0 | Low | Quality point deducted for sparse data; directness point deducted for composite outcome (return visit or hospital admission) |
| 1 (129) | Symptom severity | Oral dexamethasone plus nebulised budesonide versus nebulised budesonide alone | 4 | –1 | 0 | 0 | 0 | Moderate | Quality point deducted for sparse data |
| 1 (129) | Need for additional medical attention/admission to hospital | Oral dexamethasone plus nebulised budesonide versus nebulised budesonide alone | 4 | –1 | 0 | –1 | 0 | Low | Quality point deducted for sparse data; directness point deducted for small number of events (0 events in total) |
| 3 (254) | Symptom severity | Oral dexamethasone plus nebulised budesonide versus oral dexamethasone alone | 4 | 0 | –1 | 0 | 0 | Moderate | Consistency point deducted for significant heterogeneity between trials |
| 3 (252) | Need for additional medical attention/admission to hospital | Oral dexamethasone plus nebulised budesonide versus oral dexamethasone alone | 4 | –1 | 0 | –1 | 0 | Low | Quality point deducted for incomplete reporting of results; directness point deducted for composite outcome (return visit or hospital admission) |
| 4 (at least 131) | Symptom severity | Nebulised adrenaline (epinephrine) versus placebo or no treatment | 4 | –1 | –1 | 0 | 0 | Low | Quality point deducted for sparse data; consistency point deducted for conflicting results |
| 2 (91) | Need for additional medical attention/admission to hospital | Nebulised adrenaline (epinephrine) versus placebo or no treatment | 4 | –1 | –1 | 0 | 0 | Low | Quality point deducted for sparse data; consistency point deducted for conflicting results |
| 1 (29) | Symptom severity | Nebulised adrenaline (epinephrine) versus heliox (helium-oxygen mixture) | 4 | –2 | –1 | 0 | 0 | Very low | Quality points deducted for sparse data and incomplete reporting of results; consistency point deducted for conflicting results at different time points |
| 1 (28) | Symptom severity | L-adrenaline versus racemic adrenaline (epinephrine) | 4 | –1 | –1 | 0 | 0 | Low | Quality points deducted for sparse data; consistency point deducted for conflicting results |
| 1 (30) | Need for additional medical attention/admission to hospital | L-adrenaline versus racemic adrenaline (epinephrine) | 4 | –1 | 0 | –1 | 0 | Low | Quality point deducted for sparse data; directness point deducted for small number of events (3 events in total in 1 RCT) |
| 1 (15) | Symptom severity | Heliox (helium-oxygen mixture) versus oxygen alone | 4 | –2 | 0 | 0 | 0 | Low | Quality points deducted for sparse data and short follow-up |
| 4 (275) | Symptom severity | Humidified air versus non-humidified or low humidified air | 4 | –1 | 0 | 0 | 0 | Moderate | Quality point deducted for incomplete reporting of results |
We initially allocate 4 points to evidence from RCTs, and 2 points to evidence from observational studies. To attain the final GRADE score for a given comparison, points are deducted or added from this initial score based on preset criteria relating to the categories of quality, directness, consistency, and effect size. Quality: based on issues affecting methodological rigour (e.g., incomplete reporting of results, quasi-randomisation, sparse data [<200 people in the analysis]). Consistency: based on similarity of results across studies. Directness: based on generalisability of population or outcomes. Effect size: based on magnitude of effect as measured by statistics such as relative risk, odds ratio, or hazard ratio.