Mean baseline rate

30.62

7 (5 to 12)

Smallest baseline rate

2.06

102 (78 to 179)

Largest baseline rate

72.00

3 (2 to 5)

Dexamethasone compared to budesonide for croup

Patient or population: children with croup
Setting: emergency department, inpatients and outpatients
Intervention: dexamethasone
Comparison: budesonide

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 −2.93 to −2.00.

The mean change in croup score was 0.46 standard deviations in favour (0.79 more to 0.13 more).

‐

326
(4 RCTs)

⊕⊕⊝⊝
Low^a,b

A standard deviation of 0.46 represents a moderate 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 −3.07 to −2.33.

The mean change in croup score was 0.75 standard deviations in favour (1.19 more to 0.30 more).

‐

84
(2 RCTs)

⊕⊕⊝⊝
Low^c,d

A standard deviation of 0.75 represents a large difference between groups.

Return visits or (re)admissions or both

Study population

RR 0.69
(0.40 to 1.22)

374
(5 RCTs)

⊕⊕⊕⊝
Moderate^e

122 per 1000

84 per 1000

(49 to 149)

Adverse events

4/6 (67%) studies reported collecting adverse events data, and 3/4 (75%) studies reported no serious adverse events (Duman 2005; Johnson 1998; Vad Pedersen 1998). Klassen 1998 reported 1 case of oral thrush in the budesonide group (1/65, 1.5%) and 1 case each of hives and violent behaviour in the dexamethasone group (2/69, 2.9%).

335

(4 RCTs)

⊕⊕⊝⊝
Low^f,g

*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.

Dexamethasone compared to beclomethasone for croup

Patient or population: children with croup
Setting: emergency department, inpatients and outpatients
Intervention: dexamethasone
Comparison: beclomethasone

Return visits or (re)admissions or both

Study population

RD 0.00
(−0.09 to 0.09)

39
(1 RCT)

⊕⊕⊕⊝
Moderate^a

0 per 1000

0 per 1000

(0 to 0)

Adverse events (no events)

Eboriadou 2010 reported no adverse events related to the glucocorticoids.

39

(1 RCT)

⊕⊕⊝⊝
Low^b,c

*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).

CI: confidence interval; RCT: randomised controlled trial; RD: risk difference

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.

Dexamethasone compared to betamethasone for croup

Patient or population: children with croup
Setting: emergency department, inpatients and outpatients
Intervention: dexamethasone
Comparison: betamethasone

Change in croup score. Assessed with the Westley croup score. Lower scores mean fewer symptoms. 

(Follow‐up: 2 hours)
 

The mean change in croup score from 1 study was −1.68.

The mean change in croup score was 0.62 units in favour (1.17 more to 0.06 more).

‐

52
(1 RCT)

⊕⊕⊝⊝
Low^a,b

Change in croup score. Assessed with the Westley croup score. Lower scores mean fewer symptoms. 

(Follow‐up: 6 hours)

The mean change in croup score from 1 study was −1.89.

The mean change in croup score was 0.67 units in favour (1.23 more to 0.11 more).

‐

52
(1 RCT)

⊕⊕⊝⊝
Low^b,c

Return visits or (re)admissions or both

Study population

RR 0.95
(0.67 to 1.34)

52
(1 RCT)

⊕⊕⊝⊝
Low^d

731 per 1000

694 per 1000

(490 to 979)

Adverse events

Amir 2006 did not report collecting adverse events data.

52
(1 RCT)

⊕⊕⊝⊝
Low^a,e

*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).

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.

Dexamethasone compared to prednisolone for croup

Patient or population: children with croup
Setting: emergency department, inpatients and outpatients
Intervention: dexamethasone
Comparison: prednisolone

Change in croup score. Assessed with the Westley croup score. Lower scores mean fewer symptoms.

(Follow‐up: 2 hours)
 

The mean change in croup score from 1 study was −0.89.

The mean change in croup score was 0.06 units not in favour (0.06 more to 0.18 less).

‐

1231
(1 RCT)

⊕⊕⊕⊕
High

Change in croup score. Assessed with the Westley croup score. Lower scores mean fewer symptoms.

(Follow‐up: 6 hours)

The mean change in croup score from 1 study was −2.35.

The mean change in croup score was 0.21 units not in favour (0.21 more to 0.62 less).

‐

99
(1 RCT)

⊕⊕⊕⊝
Moderate^a

Return visits or (re)admissions or both

Study population

RR 0.55
(0.28 to 1.11)

1537
(4 RCTs)

⊕⊕⊕⊝
Moderate^b

212 per 1000

117 per 1000
(59 to 236)

Adverse events

Fifoot 2007, Garbutt 2013, and Sparrow 2006 reported no serious adverse events related to the glucocorticoids. Parker 2019 reported 1 case of insomnia (1/411, 0.24%) and 13 cases of vomiting (13/411, 3.3%) in the prednisolone group, and 29 cases of vomiting (29/820, 3.5%), 1 case of 30‐second febrile convulsion (1/820, 0.1%), and 1 case of hyperactivity (1/820, 0.1%) in the dexamethasone group.

1550
(4 RCTs)

⊕⊕⊕⊝
Moderate^c

*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).

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.

Budesonide compared to dexamethasone for croup

Patient or population: children with croup
Setting: emergency department, inpatients and outpatients
Intervention: budesonide
Comparison: dexamethasone

Adverse events

Huang 2021 reported no adverse events.

92
(1 RCT)

⊕⊕⊕⊝
Moderate^a

*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).

CI: confidence interval; RCT: randomised controlled trial

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.

Budesonide and dexamethasone compared to dexamethasone for croup

Patient or population: children with croup
Setting: emergency department, inpatients and outpatients
Intervention: budesonide and dexamethasone
Comparison: dexamethasone

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 −3.24 to −1.80.

The mean change in croup score was 0.05 standard deviations not in favour (0.19 more to 0.30 less).

‐

255
(3 RCTs)

⊕⊕⊕⊝
Moderate^a

A standard deviation of 0.05 represents a minimal difference between groups.

Return visits or (re)admissions or both

Study population

RR 0.91
(0.45 to 1.83)

254
(3 RCTs)

⊕⊕⊝⊝
Low^b

100 per 1000

91 per 1000
(45 to 183)

Adverse events

1/3 (33%) studies reported collecting adverse events data. Klassen 1998 reported no adverse events in either the dexamethasone group or the dexamethasone and budesonide group.

133

(1 RCTs)

⊕⊕⊕⊝
Moderate^c

*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.

Budesonide and dexamethasone compared to budesonide for croup

Patient or population: children with croup
Setting: emergency department, inpatients and outpatients
Intervention: budesonide and dexamethasone
Comparison: budesonide

Change in croup score. Assessed with the Westley croup score. Lower scores mean fewer symptoms.

(Follow‐up: 6 hours)

The mean change in croup score from 1 study was −2.30.

The mean change in croup score was 0.18 units in favour (0.52 more to 0.17 less).

‐

129
(1 RCT)

⊕⊕⊕⊝
Moderate^a

Return visits or (re)admissions or both

Study population

RD 0.00
(−0.03 to 0.03)

129
(1 RCT)

⊕⊕⊕⊝
Moderate^a

0 per 1000

0 per 1000
(0 to 0)

Adverse events

Klassen 1998 reported 1 case of oral thrush in the budesonide group (1/65, 1.5%) and no adverse events in the dexamethasone and budesonide group.

129
(1 RCT)

⊕⊕⊕⊝
Moderate^b

*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).

CI: confidence interval; RCT: randomised controlled trial; RD: risk difference

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.

Oral dexamethasone compared to intramuscular dexamethasone for croup

Patient or population: children with croup
Setting: emergency department, inpatients and outpatients
Intervention: oral dexamethasone
Comparison: intramuscular dexamethasone

Return visits or (re)admissions or both

Study population

RR 0.81
(0.58 to 1.12)

440
(3 RCTs)

⊕⊕⊕⊝
Moderate^a

259 per 1000

210 per 1000
(150 to 290)

Adverse events

None of the studies reported collecting adverse events data.

*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).

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.

Oral dexamethasone compared to nebulised dexamethasone for croup

Patient or population: children with croup
Setting: emergency department, inpatients and outpatients
Intervention: oral dexamethasone
Comparison: nebulised dexamethasone

Return visits or (re)admissions or both

Study population

RR 0.39
(0.17 to 0.89)

176
(1 RCT)

⊕⊕⊕⊝
Moderate^a

209 per 1000

81 per 1000
(35 to 186)

Adverse events

None of the studies reported collecting adverse events data.

*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).

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.

Dexamethasone 0.30 mg/kg compared to dexamethasone 0.15 mg/kg for croup

Patient or population: children with croup
Setting: emergency department, inpatients and outpatients
Intervention: dexamethasone 0.30 mg/kg
Comparison: dexamethasone 0.15 mg/kg

Return visits or (re)admissions or both

Study population

RR 0.94
(0.06 to 14.27)

60
(1 RCT)

⊕⊕⊝⊝
Low^a

34 per 1000

32 per 1000
(2 to 492)

Adverse events

Geelhoed 1995b did not report collecting adverse events data.

60
(1 RCT)

⊕⊕⊝⊝
Low^a,b

*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).

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.

Dexamethasone 0.60 mg/kg compared to dexamethasone 0.30 mg/kg for croup

Patient or population: children with croup
Setting: emergency department, inpatients and outpatients
Intervention: dexamethasone 0.60 mg/kg
Comparison: dexamethasone 0.30 mg/kg

Return visits or (re)admissions or both

Study population

RR 1.40
(0.25 to 7.81)

60
(1 RCT)

⊕⊕⊝⊝
Low^a

69 per 1000

97 per 1000
(17 to 539)

Adverse events

Geelhoed 1995a did not report collecting adverse events data.

60
(1 RCT)

⊕⊝⊝⊝
Very low^a,b

*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).

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.

Dexamethasone 0.60 mg/kg compared to dexamethasone 0.15 mg/kg for croup

Patient or population: children with croup
Setting: emergency department, inpatients and outpatients
Intervention: dexamethasone 0.60 mg/kg
Comparison: dexamethasone 0.15 mg/kg

Change in croup score. Assessed with the Westley croup score. Lower scores mean fewer symptoms.

(Follow‐up: 2 hours)

The mean change in croup score was −1.05 to −0.75.

The mean change in croup score was 0.27 standard deviations in favour
(0.76 more to 0.22 less).

‐

861
(2 RCTs)

⊕⊕⊕⊕
High

A standard deviation of 0.14 represents a small difference between groups.

Change in croup score. Assessed with the Westley croup score. Lower scores mean fewer symptoms.

(Follow‐up: 6 hours)

The mean change in croup score was −3.10 to −2.09.

The mean change in croup score was 0.45 units in favour (1.26 more to 0.35 less).

‐

178
(3 RCTs)

⊕⊕⊕⊝
Moderate^a

Change in croup score. Assessed with the Westley croup score. Lower scores mean fewer symptoms.

(Follow‐up: 12 hours)

The mean change in croup score was −3.50 to −2.95.

The mean change in croup score was 0.60 units in favour (4.39 more to 3.19 less).

‐

113
(2 RCTs)

⊕⊝⊝⊝
Very Low^b,c

Change in croup score. Assessed with the Westley croup score. Lower scores mean fewer symptoms.

(Follow‐up: 24 hours)

The mean change in croup score from 1 study was −4.00.

The mean change in croup score was 0.63 units not in favour (0.16 less to 1.10 less).

‐

72
(1 RCT)

⊕⊕⊕⊝
Moderate^a

Return visits or (re)admissions or both

Study population

RR 0.91
(0.71 to 1.17)

949
(3 RCTs)

⊕⊕⊕⊕
High

208 per 1000

189 per 1000
(148 to 243)

Adverse events

Parker 2019 reported 16 cases of vomiting (16/410, 4.0%) and 1 case of 30 seconds of febrile convulsion (1/410, 0.2%) in the 0.60 mg/kg dexamethasone group, and 13 cases of vomiting (13/410 (3.3%), 1 case of stridor (1/410, 0.2%), and 1 case of hyperactivity (1/410, 0.2%) in the 0.15 mg/kg dexamethasone group. Alshehr 2005 reported 1 case of bacterial tracheitis and 2 cases of bronchopneumonia in the 0.60 mg/kg dexamethasone group (3/36, 8.3%) and no adverse events in the 0.15 mg/kg dexamethasone group. Chub‐Uppakarn 2007 and Fifoot 2007 reported no adverse events in either treatment group.

170
(3 RCTs)

⊕⊕⊕⊝
Moderate^d

*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.