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Study flow diagram.
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Figure 1

Study flow diagram.

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Risk of bias summary: review authors' judgements about each risk of bias item for each included study.
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Figure 2

Risk of bias summary: review authors' judgements about each risk of bias item for each included study.

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Forest plot of comparison: 1 Interventions for autumn exacerbations of asthma versus usual care, outcome: 1.1 Exacerbations defined according to the review's primary outcome.
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Figure 3

Forest plot of comparison: 1 Interventions for autumn exacerbations of asthma versus usual care, outcome: 1.1 Exacerbations defined according to the review's primary outcome.

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Forest plot of comparison: 1 Interventions for autumn exacerbations of asthma versus usual care, outcome: 1.2 Exacerbations defined according to study‐specific definitions.
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Figure 4

Forest plot of comparison: 1 Interventions for autumn exacerbations of asthma versus usual care, outcome: 1.2 Exacerbations defined according to study‐specific definitions.

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Forest plot of comparison: 1 Interventions for autumn exacerbations of asthma versus usual care, outcome: 1.3 Adverse effects.
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Figure 5

Forest plot of comparison: 1 Interventions for autumn exacerbations of asthma versus usual care, outcome: 1.3 Adverse effects.

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Comparison 1 Interventions for autumn exacerbations of asthma versus usual care, Outcome 1 Exacerbations defined according to the review's primary outcome.
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Analysis 1.1

Comparison 1 Interventions for autumn exacerbations of asthma versus usual care, Outcome 1 Exacerbations defined according to the review's primary outcome.

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Comparison 1 Interventions for autumn exacerbations of asthma versus usual care, Outcome 2 Exacerbations defined according to study‐specific definitions.
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Analysis 1.2

Comparison 1 Interventions for autumn exacerbations of asthma versus usual care, Outcome 2 Exacerbations defined according to study‐specific definitions.

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Comparison 1 Interventions for autumn exacerbations of asthma versus usual care, Outcome 3 Adverse effects.
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Analysis 1.3

Comparison 1 Interventions for autumn exacerbations of asthma versus usual care, Outcome 3 Adverse effects.

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Summary of findings for the main comparison. Omalizumab compared to usual care for autumn asthma exacerbations in children

Omalizumab compared to usual care for autumn asthma exacerbations in children

Patient or population: autumn asthma exacerbations in children

Setting: community
Intervention: omalizumab
Comparison: usual care

Outcomes

Anticipated absolute effects* (95% CI)

Relative effect
(95% CI)

№ of participants
(studies)

Quality of the evidence
(GRADE)

Comments

Risk with usual care

Risk with omalizumab

Exacerbations
assessed with: hospital admissions or oral steroid requirement in those with stage 2‐5 asthma
follow‐up: 90 days

210 per 1000

113 per 1000

(62 to 197)

OR 0.48 (0.25 to 0.92)

348

(1 RCT)

⊕⊕⊕⊝
MODERATE 1

Absolute effects calculated using control risk of 21.0% from Teach 2015a.

Exacerbations
assessed with: hospital admissions or OCS requirement in those with stage 5 asthma
follow‐up: 90 days

326 per 1000

152 per 1000
(76 to 281)

OR 0.37
(0.17 to 0.81)

184
(1 RCT)

⊕⊕⊕⊝
MODERATE 1

Absolute effects calculated using control risk of 32.6% from Teach 2015a.

Exacerbations
assessed with: hospital admissions or OCS requirement in those with stage 2‐4 asthma
follow‐up: 90 days

127 per 1000

83 per 1000
(31 to 207)

OR 0.63
(0.22 to 1.79)

164
(1 RCT)

⊕⊕⊕⊝
MODERATE 1

Absolute effects calculated using control risk of 12.7% from Teach 2015a.

Adverse events
assessed with: number of children experiencing 1 or more adverse events asthma stage 2‐5
follow‐up: 17 to 19 weeks

548 per 1000

546 per 1000
(425 to 657)

OR 0.99
(0.61 to 1.58)

361
(1 RCT)

⊕⊕⊕⊝
MODERATE 1

*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; OCS: oral corticosteroid; OR: odds ratio; RCT: randomised controlled trial

GRADE Working Group grades of evidence
High quality: We are very confident that the true effect lies close to that of the estimate of the effect.
Moderate quality: 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 quality: Our confidence in the effect estimate is limited: the true effect may be substantially different from the estimate of the effect.
Very low quality: We have very little confidence in the effect estimate: the true effect is likely to be substantially different from the estimate of effect.

1Downgraded once for imprecision because few children studied.

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Summary of findings for the main comparison. Omalizumab compared to usual care for autumn asthma exacerbations in children
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Summary of findings 2. A boost of inhaled corticosteroids compared to usual care for autumn asthma exacerbations in children

A boost of inhaled corticosteroids compared to usual care for autumn asthma exacerbations in children

Patient or population: autumn asthma exacerbations in children

Setting: community
Intervention: a boost of inhaled corticosteroids
Comparison: usual care

Outcomes

Anticipated absolute effects* (95% CI)

Relative effect
(95% CI)

№ of participants
(studies)

Quality of the evidence
(GRADE)

Comments

Risk with usual care

Risk with a boost of inhaled corticosteroids

Exacerbations
assessed with: hospital admission or oral corticosteroid requirement asthma stages 2‐4
follow‐up: 90 days

127 per 1000

111 per 1000
(44 to 251)

OR 0.86
(0.32 to 2.30)

173
(1 RCT)

⊕⊕⊕⊝
MODERATE 1

Absolute effects calculated using control risk of 12.7% from Teach 2015a.

Adverse events
assessed with: number of children experiencing 1 or more adverse events asthma stage 2‐4
follow‐up: 17 to 19 weeks

533 per 1000

434 per 1000
(280 to 603)

OR 0.67
(0.34 to 1.33)

176
(1 RCT)

⊕⊕⊕⊝
MODERATE 1

*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; OR: odds ratio; RCT: randomised controlled trial

GRADE Working Group grades of evidence
High quality: We are very confident that the true effect lies close to that of the estimate of the effect.
Moderate quality: 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 quality: Our confidence in the effect estimate is limited: the true effect may be substantially different from the estimate of the effect.
Very low quality: We have very little confidence in the effect estimate: the true effect is likely to be substantially different from the estimate of effect.

1Downgraded once for imprecision because few children studied.

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Summary of findings 2. A boost of inhaled corticosteroids compared to usual care for autumn asthma exacerbations in children
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Summary of findings 3. Leukotriene receptor antagonist compared to usual care for autumn asthma exacerbations in children

Leukotriene receptor antagonist (LTRA) compared to usual care for autumn asthma exacerbations in children

Patient or population: autumn asthma exacerbations in children

Setting: community
Intervention: LTRA
Comparison: usual care

Outcomes

Anticipated absolute effects* (95% CI)

Relative effect
(95% CI)

№ of participants
(studies)

Quality of the evidence
(GRADE)

Comments

Risk with usual care

Risk with montelukast

Exacerbations

assessed with: oral corticosteroid or hospitalisation

‐

‐

‐

‐

‐

Not reported

Exacerbations
assessed with: unscheduled medical contacts
follow‐up: range 45 days to 8 weeks

146 per 1000

79 per 1000
(28 to 200)

OR 0.50
(0.17 to 1.46)

1326
(2 RCTs)

⊕⊕⊝⊝
LOW 1 2

Absolute effects calculated using control risk of 14.6% from Johnston 2007.

Adverse events
assessed with: number of children experiencing 1 or more adverse events
follow‐up: range 45 days to 10 weeks

328 per 1000

307 per 1000
(235 to 392)

OR 0.91
(0.63 to 1.32)

1326
(2 RCTs)

⊕⊕⊕⊕
HIGH

*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; OR: odds ratio; RCT: randomised controlled trial

GRADE Working Group grades of evidence
High quality: We are very confident that the true effect lies close to that of the estimate of the effect.
Moderate quality: 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 quality: Our confidence in the effect estimate is limited: the true effect may be substantially different from the estimate of the effect.
Very low quality: We have very little confidence in the effect estimate: the true effect is likely to be substantially different from the estimate of effect.

1Downgraded once for inconsistency because asthma severity of children differed between included studies, and thresholds for medical contact or oral steroids appeared to differ between studies.
2Downgraded once for indirectness since studies contained no data on hospitalisation and need for oral steroids, so unscheduled medical contacts used as a proxy.

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Summary of findings 3. Leukotriene receptor antagonist compared to usual care for autumn asthma exacerbations in children
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Summary of findings 4. Behavioural intervention compared to usual care for autumn asthma exacerbations in children

Behavioural intervention compared to usual care for autumn asthma exacerbations in children

Patient or population: autumn asthma exacerbations in children
Setting: community
Intervention: behavioural intervention
Comparison: usual care

Outcomes

Anticipated absolute effects* (95% CI)

Relative effect
(95% CI)

№ of participants
(studies)

Quality of the evidence
(GRADE)

Comments

Risk with usual care

Risk with behavioural intervention

Exacerbations
assessed with: oral corticosteroid or hospitalisation

‐

‐

‐

‐

‐

Not reported

Exacerbations
assessed with: unscheduled contact for respiratory diagnosis
follow‐up: 4 months

167 per 1000

185 per 1000
(160 to 211)

OR 1.13
(0.95 to 1.33)

10,481
(1 RCT)

⊕⊕⊕⊝
MODERATE 1

Absolute effects calculated using control rate of 16.7% from Julious 2016.

Adverse events

‐

‐

‐

‐

‐

Not reported

*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; OR: odds ratio; RCT: randomised controlled trial

GRADE Working Group grades of evidence
High quality: We are very confident that the true effect lies close to that of the estimate of the effect.
Moderate quality: 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 quality: Our confidence in the effect estimate is limited: the true effect may be substantially different from the estimate of the effect.
Very low quality: We have very little confidence in the effect estimate: the true effect is likely to be substantially different from the estimate of effect.

1Downgraded once for indirectness because studies contained no data on hospitalisation and need for oral steroids, so unscheduled contacts for a respiratory diagnosis used as a proxy outcome.

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Summary of findings 4. Behavioural intervention compared to usual care for autumn asthma exacerbations in children
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Comparison 1. Interventions for autumn exacerbations of asthma versus usual care

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Exacerbations defined according to the review's primary outcome Show forest plot

1

Odds Ratio (Random, 95% CI)

Subtotals only

1.1 Omalizumab interventions

1

348

Odds Ratio (Random, 95% CI)

0.48 [0.25, 0.92]

1.2 Omalizumab intervention (stage 5 asthma)

1

184

Odds Ratio (Random, 95% CI)

0.37 [0.17, 0.81]

1.3 Steroid boost intervention (stage 2‐4 asthma)

1

173

Odds Ratio (Random, 95% CI)

0.86 [0.32, 2.31]

2 Exacerbations defined according to study‐specific definitions Show forest plot

4

Odds Ratio (Random, 95% CI)

Subtotals only

2.1 Montelukast interventions

2

1192

Odds Ratio (Random, 95% CI)

0.50 [0.17, 1.46]

2.2 Pranlukast intervention

1

121

Odds Ratio (Random, 95% CI)

0.67 [0.16, 2.80]

2.3 Behavioural intervention

1

9118

Odds Ratio (Random, 95% CI)

1.13 [0.96, 1.34]

3 Adverse effects Show forest plot

3

Odds Ratio (M‐H, Random, 95% CI)

Subtotals only

3.1 Omalizumab intervention (stage 2‐5 asthma)

1

361

Odds Ratio (M‐H, Random, 95% CI)

0.99 [0.61, 1.58]

3.2 Steroid boost intervention (stage 2‐4 asthma)

1

176

Odds Ratio (M‐H, Random, 95% CI)

0.67 [0.34, 1.33]

3.3 LTRA interventions

2

1326

Odds Ratio (M‐H, Random, 95% CI)

0.91 [0.63, 1.32]
Figuras y tablas -
Comparison 1. Interventions for autumn exacerbations of asthma versus usual care
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