title: Nebulised steroid in the treatment of croup: a systematic review of randomised controlled trials.
abstract: BACKGROUND
  Croup is one of the commonest respiratory complaints among children. There is growing evidence that steroids may be an effective treatment.
  
  
  OBJECTIVE
  To assess the effectiveness of treatment with nebulised steroid for children with croup.
  
  
  METHODS
  Systematic review of randomised controlled trials comparing administration of nebulised steroid with placebo. Trials were identified from searches of three bibliographic databases, the Cochrane Controlled Trials Register, correspondence with the manufacturers of nebulised steroid, and one round of manual citation searching.
  
  
  RESULTS
  Eight randomised controlled trials were identified including 574 children with mild to severe croup. Overall, the mean age was 25.2 months and 72% of children were male. All trials were hospital-based and of good methodological quality, with adequate concealment of treatment allocation and blind outcome assessment. Children treated with nebulised steroid were significantly more likely to show an improvement in croup score by five hours (combined relative risk = 1.48, 95% confidence interval [CI] = 1.27 to 1.74) and significantly less likely to need hospital admission after attending the emergency department (combined relative risk = 0.56, 95% CI = 0.42 to 0.75) than the placebo group. The funnel plot indicated the presence of publication bias, with smaller studies showing the larger effects, but this could also be owing to less pronounced effects in studies of older children with milder croup.
  
  
  CONCLUSIONS
  Nebulised steroids are effective in the treatment of children attending hospital departments with croup. A meta-analysis based on individual patient data could clarify to what extent the effect depends on age and severity of disease. New trials are needed to define the indications for, and effectiveness of, steroid treatment of croup in the community.
authors.affiliation: Department of Public Health and Primary Care, Institute of Public Health, Cambridge. sjg49@medschl.cam.ac.uk
authors.forename: S
authors.initials: S
authors.lastname: Griffin
authors.forename: S
authors.initials: S
authors.lastname: Ellis
authors.forename: A
authors.initials: A
authors.lastname: Fitzgerald-Barron
authors.forename: J
authors.initials: J
authors.lastname: Rose
authors.forename: M
authors.initials: M
authors.lastname: Egger
mesh_terms: D000893:Anti-Inflammatory Agents / Q000008:administration & dosage*; D019819:Budesonide / Q000008:administration & dosage; D002648:Child; D002675:Child, Preschool; D003440:Croup / Q000188:drug therapy*; D005260:Female; D006801:Humans; D007223:Infant; D008297:Male; D009330:Nebulizers and Vaporizers / Q000706:statistics & numerical data; D010919:Placebos; D016032:Randomized Controlled Trials as Topic; D006113:United Kingdom
chemical_list: D000893:Anti-Inflammatory Agents; D010919:Placebos; D019819:Budesonide