title: Steroids and bronchodilators for acute bronchiolitis in the first two years of life: systematic review and meta-analysis.
abstract: OBJECTIVE
  To evaluate and compare the efficacy and safety of bronchodilators and steroids, alone or combined, for the acute management of bronchiolitis in children aged less than 2 years.
  
  
  METHODS
  Systematic review and meta-analysis.
  
  
  METHODS
  Medline, Embase, Central, Scopus, PubMed, LILACS, IranMedEx, conference proceedings, and trial registers. Inclusion criteria Randomised controlled trials of children aged 24 months or less with a first episode of bronchiolitis with wheezing comparing any bronchodilator or steroid, alone or combined, with placebo or another intervention (other bronchodilator, other steroid, standard care).
  
  
  METHODS
  Two reviewers assessed studies for inclusion and risk of bias and extracted data. Primary outcomes were selected by clinicians a priori based on clinical relevance: rate of admission for outpatients (day 1 and up to day 7) and length of stay for inpatients. Direct meta-analyses were carried out using random effects models. A mixed treatment comparison using a Bayesian network model was used to compare all interventions simultaneously.
  
  
  RESULTS
  48 trials (4897 patients, 13 comparisons) were included. Risk of bias was low in 17% (n = 8), unclear in 52% (n = 25), and high in 31% (n = 15). Only adrenaline (epinephrine) reduced admissions on day 1 (compared with placebo: pooled risk ratio 0.67, 95% confidence interval 0.50 to 0.89; number needed to treat 15, 95% confidence interval 10 to 45 for a baseline risk of 20%; 920 patients). Unadjusted results from a single large trial with low risk of bias showed that combined dexamethasone and adrenaline reduced admissions on day 7 (risk ratio 0.65, 0.44 to 0.95; number needed to treat 11, 7 to 76 for a baseline risk of 26%; 400 patients). A mixed treatment comparison supported adrenaline alone or combined with steroids as the preferred treatments for outpatients (probability of being the best treatment based on admissions at day 1 were 45% and 39%, respectively). The incidence of reported harms did not differ. None of the interventions examined showed clear efficacy for length of stay among inpatients.
  
  
  CONCLUSIONS
  Evidence shows the effectiveness and superiority of adrenaline for outcomes of most clinical relevance among outpatients with acute bronchiolitis, and evidence from a single precise trial for combined adrenaline and dexamethasone.
authors.affiliation: Alberta Research Centre for Health Evidence, Department of Pediatrics, University of Alberta, 11402 University Avenue, Edmonton, AB, Canada T6G 2J3. hartling@ualberta.ca
authors.forename: Lisa
authors.initials: L
authors.lastname: Hartling
authors.forename: Ricardo M
authors.initials: RM
authors.lastname: Fernandes
authors.forename: Liza
authors.initials: L
authors.lastname: Bialy
authors.forename: Andrea
authors.initials: A
authors.lastname: Milne
authors.forename: David
authors.initials: D
authors.lastname: Johnson
authors.forename: Amy
authors.initials: A
authors.lastname: Plint
authors.forename: Terry P
authors.initials: TP
authors.lastname: Klassen
authors.forename: Ben
authors.initials: B
authors.lastname: Vandermeer
mesh_terms: D000553:Ambulatory Care; D001988:Bronchiolitis / Q000188:drug therapy*; D001993:Bronchodilator Agents / Q000627:therapeutic use*; D004359:Drug Therapy, Combination; D006760:Hospitalization; D006801:Humans; D007223:Infant; D016032:Randomized Controlled Trials as Topic; D013256:Steroids / Q000627:therapeutic use*
chemical_list: D001993:Bronchodilator Agents; D013256:Steroids