Summary of findings for the main comparison. Any glucocorticoid compared to placebo for croup.
| Any glucocorticoid compared to placebo for croup | ||||||
| Patient or population: children with croup Intervention: any glucocorticoid Comparison: placebo | ||||||
| Outcomes | Anticipated absolute effects* (95% CI) | Relative effect (95% CI) | № of participants (studies) | Certainty of the evidence (GRADE) | Comments** | |
| Placebo | Any glucocorticoid | |||||
| Change in croup score. Assessed with different scores in different studies. Lower scores mean fewer symptoms. (follow‐up: 2 hours) | The mean change in croup score was ‐1.50 to ‐0.81. | The mean change in croup score was 0.65 standard deviations more (1.13 more to 0.18 more). | ‐ | 426 (7 RCTs) | ⊕⊕⊕⊝ MODERATEa | A standard deviation of 0.65 represents a moderate difference between groups. |
| Change in croup score. Assessed with different scores in different studies. Lower scores mean fewer symptoms. (follow‐up: 6 hours) | The mean change in croup score was ‐3.23 to ‐0.65. | The mean change in croup score was 0.76 standard deviations more (1.12 more to 0.40 more). | ‐ | 959 (11 RCTs) | ⊕⊕⊕⊝ MODERATEb | A standard deviation of 0.76 represents a large difference between groups. |
| Change in croup score. Assessed with different scores in different studies. Lower scores mean fewer symptoms. (follow‐up: 12 hours) | The mean change in croup score was ‐7.62 to ‐1.00. | The mean change in croup score was 1.03 standard deviations more (1.53 more to 0.53 more). | ‐ | 571 (8 RCTs) | ⊕⊕⊕⊝ MODERATEc | A standard deviation of 1.03 represents a large difference between groups. |
| Change in croup score. Assessed with different scores in different studies. Lower scores mean fewer symptoms. (follow‐up: 24 hours) | The mean change in croup score was ‐2.56 to ‐1.05. | The mean change in croup score was 0.86 standard deviations more (1.40 more to 0.31 more). | ‐ | 351 (8 RCTs) | ⊕⊕⊝⊝ LOWd | A standard deviation of 0.86 represents a large difference between groups. |
| Return visits or (re)admissions or both | Study population | RR 0.52 (0.36 to 0.75) | 1679 (10 RCTs) | ⊕⊕⊕⊝ MODERATEe | ||
| 204 per 1000 | 106 per 1000 (74 to 153) | |||||
| Adverse events | 13/26 (50%) studies reported collecting adverse events data, and 8/13 (62%) reported no serious adverse events. Bjornson 2004 reported 7 instances of pneumonia (3/359, 0.83% in the dexamethasone group and 4/361, 1.11% in the placebo group). Johnson 1996 reported 1 child with neutropenia consistent with bacterial tracheitis in the dexamethasone group (1/28, 3.57%). Kuusela 1988 reported 7 secondary bacterial infections (pneumonia, sinusitis, otitis media) requiring antibiotic therapy: 5/35, 14% in the dexamethasone group and 2/16, 12.5% in the placebo group. Super 1989 reported 1 child with pneumonitis in the placebo group (1/13, 7.7%) and 2 children with pneumonia in the dexamethasone group (2/16, 12.5%). Roberts 1999 reported 1 instance of exacerbated symptoms, 5 children with emotional distress, 2 with vomiting, and 1 instance of eye irritation in the budesonide group (9/42, 21.4%) and 3 instances of exacerbated symptoms, 6 children with emotional distress, 3 with vomiting, 2 rashes, and 1 instance each of eye irritation and tongue irritation in the placebo group (16/40, 40%). | |||||
| *The risk in the intervention group (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI).
**We used Cohen's interpretation of effect sizes to determine the magnitude of the difference between groups (0.2 represents a small effect, 0.5 represents a medium effect, 0.8 represents a large effect). CI: confidence interval; RCT: randomised controlled trial; RR: risk ratio | ||||||
| GRADE Working Group grades of evidence High certainty: We are very confident that the true effect lies close to that of the estimate of the effect. Moderate certainty: We are moderately confident in the effect estimate: the true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different. Low certainty: Our confidence in the effect estimate is limited: the true effect may be substantially different from the estimate of the effect. Very low certainty: We have very little confidence in the effect estimate: the true effect is likely to be substantially different from the estimate of effect. | ||||||
aWe downgraded by one level for inconsistency. There was considerable heterogeneity (I² = 81%), and variation in point estimates. bWe downgraded by one level for inconsistency. There was considerable heterogeneity (I² = 83%), and variation in point estimates and in direction of effects for one study. cWe downgraded by one level for inconsistency. There was considerable heterogeneity (I² = 86%), and variation in point estimates. dWe downgraded by two levels for inconsistency. There was considerable heterogeneity (I² = 81%), and variation in point estimates. The confidence intervals did not overlap for some studies. There was variation in the direction of effects. eWe downgraded by one level for inconsistency. There was substantial heterogeneity (I² = 52%), and variation in point estimates.