BMJ 1999;319:595-600 ( 4 September )

Papers

The effectiveness of glucocorticoids in treating croup: meta-analysis

Monica Ausejo, visiting fellow, ^a Antonio Saenz, visiting fellow, ^a Ba' Pham, statistician, ^a James D Kellner, assistant professor, ^b David W Johnson, assistant professor, ^b David Moher, director, ^a Terry P Klassen, director, children's hospital. ^a

^a Thomas C Chalmer's Center for Systematic Reviews, Children's Hospital of Eastern Ontario Research Institute, 401 Smyth Road, Ottawa, Ontario K1H 8LI, Canada, ^b Department of Pediatrics, University of Calgary, Alberta Children's Hospital, 1820 Richmond Road, Calgary, Alberta T2T 5C7, Canada

Correspondence to: TP Klassen Department of Pediatrics, University of Alberta, 2C3.67 Walter C Mackenzie Health Sciences Center, Edmonton, Alberta T6G 2R7 terry.klassen{at}sympatico.ca

Objective: To determine the effectiveness of glucocorticoid treatment in children with croup.
Design: Meta-analysis of randomised controlled trials that examine the effectiveness of glucocorticoid treatment in children with croup.
Main outcome measures: Score on scale measuring severity of croup, use of cointerventions (adrenaline (epinephrine), antibiotics, or supplemental glucocorticoids), length of stay in accident and emergency or in hospital, and rate of hospitalisation.
Results: Twenty four studies met the inclusion criteria. Glucocorticoid treatment was associated with an improvement in the croup severity score at 6 hours with an effect size of 1.0 (95% confidence interval 1.5 to 0.6) and at 12 hours 1.0 (1.6 to 0.4); at 24 hours this improvement was no longer significant (1.0, 2.0 to 0.1). There was a decrease in the number of adrenaline treatments needed in children treated with glucocorticoids: a decrease of 9% (95% confidence interval 2% to 16%) among those treated with budesonide and of 12% (4% to 20%) among those treated with dexamethasone. There was also a decrease in the length of time spent in accident and emergency (11 hours, 95% confidence interval 18 to 4 hours), and for inpatients hospital stay was reduced by 16 hours (31 to 1 hour). Publication bias seems to play a part in these results.
Conclusions: Dexamethasone and budesonide are effective in relieving the symptoms of croup as early as 6 hours after treatment. Fewer cointerventions are used and the length of time spent in hospital is decreased in patients treated with glucocorticoids.

Key messages Most trials evaluating the treatment of croup are of high methodological quality and hence have a low risk of bias Publication bias, however, seems to be a problem, making the results of this meta-analysis somewhat less certain Glucocorticoids seem to bring about clinical improvement in children with croup within 6 hours Nebulised budesonide or dexamethasone, given either orally or intramuscularly, is effective in treating croup The use of glucocorticoids is associated with a lower rate of use of cointerventions and shortens the time spent in hospital

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