title: Glucocorticoids for acute viral bronchiolitis in infants and young children.
abstract: BACKGROUND
  Previous systematic reviews have not shown clear benefit of glucocorticoids for acute viral bronchiolitis, but their use remains considerable. Recent large trials add substantially to current evidence and suggest novel glucocorticoid-including treatment approaches.
  
  
  OBJECTIVE
  To review the efficacy and safety of systemic and inhaled glucocorticoids in children with acute viral bronchiolitis.
  
  
  METHODS
  We searched the Cochrane Central Register of Controlled Trials (CENTRAL 2012, Issue 12), MEDLINE (1950 to January week 2, 2013), EMBASE (1980 to January 2013), LILACS (1982 to January 2013), Scopus® (1823 to January 2013) and IRAN MedEx (1998 to November 2009).
  
  
  METHODS
  Randomised controlled trials (RCTs) comparing short-term systemic or inhaled glucocorticoids versus placebo or another intervention in children under 24 months with acute bronchiolitis (first episode with wheezing). Our primary outcomes were: admissions by days 1 and 7 for outpatient studies; and length of stay (LOS) for inpatient studies. Secondary outcomes included clinical severity parameters, healthcare use, pulmonary function, symptoms, quality of life and harms.
  
  
  METHODS
  Two authors independently extracted data on study and participant characteristics, interventions and outcomes. We assessed risk of bias and graded strength of evidence. We meta-analysed inpatient and outpatient results separately using random-effects models. We pre-specified subgroup analyses, including the combined use of bronchodilators used in a protocol.
  
  
  RESULTS
  We included 17 trials (2596 participants); three had low overall risk of bias. Baseline severity, glucocorticoid schemes, comparators and outcomes were heterogeneous. Glucocorticoids did not significantly reduce outpatient admissions by days 1 and 7 when compared to placebo (pooled risk ratios (RRs) 0.92; 95% confidence interval (CI) 0.78 to 1.08 and 0.86; 95% CI 0.7 to 1.06, respectively). There was no benefit in LOS for inpatients (mean difference -0.18 days; 95% CI -0.39 to 0.04). Unadjusted results from a large factorial low risk of bias RCT found combined high-dose systemic dexamethasone and inhaled epinephrine reduced admissions by day 7 (baseline risk of admission 26%; RR 0.65; 95% CI 0.44 to 0.95; number needed to treat 11; 95% CI 7 to 76), with no differences in short-term adverse effects. No other comparisons showed relevant differences in primary outcomes.
  
  
  CONCLUSIONS
  Current evidence does not support a clinically relevant effect of systemic or inhaled glucocorticoids on admissions or length of hospitalisation. Combined dexamethasone and epinephrine may reduce outpatient admissions, but results are exploratory and safety data limited. Future research should further assess the efficacy, harms and applicability of combined therapy.
authors.affiliation: Laboratory of Clinical Pharmacology and Therapeutics, Faculty of Medicine, University of Lisbon, Instituto de Medicina Molecular,Lisboa, Portugal. fernandescunharicardo@gmail.com
authors.forename: Ricardo M
authors.initials: RM
authors.lastname: Fernandes
authors.forename: Liza M
authors.initials: LM
authors.lastname: Bialy
authors.forename: Ben
authors.initials: B
authors.lastname: Vandermeer
authors.forename: Lisa
authors.initials: L
authors.lastname: Tjosvold
authors.forename: Amy C
authors.initials: AC
authors.lastname: Plint
authors.forename: Hema
authors.initials: H
authors.lastname: Patel
authors.forename: David W
authors.initials: DW
authors.lastname: Johnson
authors.forename: Terry P
authors.initials: TP
authors.lastname: Klassen
authors.forename: Lisa
authors.initials: L
authors.lastname: Hartling
mesh_terms: D000208:Acute Disease; D000553:Ambulatory Care; D001990:Bronchiolitis, Viral / Q000188:drug therapy*; D003907:Dexamethasone / Q000627:therapeutic use; D004837:Epinephrine / Q000627:therapeutic use; D005938:Glucocorticoids / Q000627:therapeutic use*; D006760:Hospitalization; D006801:Humans; D007223:Infant; D007231:Infant, Newborn; D016032:Randomized Controlled Trials as Topic; D012135:Respiratory Sounds / Q000209:etiology
chemical_list: D005938:Glucocorticoids; D003907:Dexamethasone; D004837:Epinephrine