Croup In Children Research Articles

Evidence for Clinicians: Nebulized epinephrine for croup in children.

epinephrine was associated with significantly shorter hospital stay compared with placebo (one RCT, MD –32.0 h [95% CI –59.1 to –4.9]). Comparing racemic and L-epinephrine, no difference in croup score was found after 30 min (SMD 0.33 [95% CI –0.42 to 1.08]). After 2 h, L-epinephrine showed significant reduction compared with racemic epinephrine (one RCT, SMD 0.87 [95% CI 0.09 to 1.65]). There was no significant difference in croup score between administration of nebulized epinephrine via IPPB versus nebulization alone at 30 min (one RCT, SMD –0.14 [95% CI –1.24 to 0.95]) or 2 h (SMD –0.72 [95% CI –1.86 to 0.42]). None of the studies sought or reported data on adverse effects. Conclusions Nebulized epinephrine is associated with clinically and statistically significant transient reduction of symptoms of croup 30 min post-treatment. Evidence does not favour racemic epinephrine or L-epinephrine, or IPPB over simple nebulization. The authors note that data and analyses were limited by the small number of relevant studies and total number of participants and, thus, most outcomes contained data from very few or even single studies. The full text of the Cochrane Review is available in The Cochrane Library (1). ExPERT CoMMENTARy Importance of the topic The annual incidence of croup is as high as 6% in children <6 years of age presenting to paediatricians’ offices and EDs (2,3). Although usually self-limited, with symptoms resolving by 48 h in 60% of cases, up to 5% of children presenting for medical care are admitted to hospital, and up to 3% of these children are intubated (2,3). In clinical settings, severity is categorized as mild, moderate, severe and respiratory failure; at least two-thirds present with mild, and <1% with severe croup (4-6). Children with croup should be kept as comfortable as possible; care must be taken not to frighten the child, and to avoid causing agitation, both of which can worsen the airway obstruction. Humidified air was traditionally used as a primary intervention; however, a Cochrane review concluded that it was ineffective (7). The benefits of corticosteroids and nebulized epinephrine have been evaluated in multiple well-designed prospective studies (1,8). In severe croup unresponsive to treatment, endotracheal intubation is indicated. Intubation can be difficult due to severe subglottic swelling. In addition, there are instances in which the symptoms of croup are due to other structural causes of upper airway obstruction, leading to a difficult airway. Thus, intubation of a child with croup should be performed by an anesthetist with the support of an ear, nose and throat specialist, ideally in the operating room. evidenCe for CliniCians

PS-320 The Relation Of Traffic Load To Traffic-dependent Pollutants And Croup: Abstract PS-320 Table 1

Objective Some studies have compared the occurrence of croup with air pollution. Results have so far remained contradictory. Motor vehicles represent the principal source of air pollution in the city of Vinnytsya, Ukraine. The objective of this study was to determine the relation of traffic load to traffic-dependent pollutants and croup. Methods Among a population of 8.067 children in residence near areas of high traffic density (>1.500 motor vehicles/ hour) and 2.473 children in residence near areas of low traffic density ( Results Areas with high traffic load are characterised by higher concentration of traffic-dependent pollutants and higher annual incidence of croup (Table). Table. Traffic load, traffic-dependent pollutants and annual incidence of croup in children (Vinnytsya, Ukraine, 2000–2003) Conclusions Croup in children is related to traffic load and traffic-dependent pollutants (SO2, NO2, particulate matter, CO).

Stability of infectious human coronavirus NL63

The human coronavirus NL63 was identified in 2004 and subsequent studies showed its worldwide distribution. Infection with this pathogen is associated with upper and lower respiratory tract diseases of mild to moderate severity. Furthermore, HCoV-NL63 is the main cause of croup in children. Within this study an optimal protocol for freeze-drying that allows safe and effective preservation of HCoV-NL63 infectious material was developed. Lyophilized virus preparations can be stored either at ambient temperature or at +4°C. In the latter case samples may be stored for at least two months. Surprisingly, conducted analysis showed that HCoV-NL63 virions are exquisitely stable in liquid media and can be stored also without preservatives at ambient temperature for up to 14 days.

成人クループの3例

Croup is an acute respiratory tract inflammation characterized by swelling of the subglottic tissue caused by an infection with respiratory viruses such as parainfluenza virus, influenza virus, adenovirus and respiratory syncytial virus. Its symptoms include fever, barking cough, stridor and hoarseness. It is a relatively common condition in childhood, especially at younger than three years of age. Since it rarely occurs in adulthood, the clinical features of adult croup are mostly unknown. We report herein on three cases of adult croup and review another 17 cases of adult croup described in the literatures written in English or Japanese. The clinical features of adult croup were compared to that of croup in children. The patients with adult croup present with symptoms such as sore throat and dysphagia in addition to the symptoms that are common for croup in children. A coronal neck X-ray revealed a characteristic narrowing of the subglottic trachea, the steeple sign, in all cases. Although flexible laryngoscopy also has a high diagnostic value, it is necessary to pay careful attention to the clinical findings of possible airway obstruction. Two of our three cases and eight of 17 reported cases required airway management, indicating a much more severe condition in adults compared to that in children. Another clinical characteristics of adult cases include that only very severe cases have been diagnosed as croup. A rise of antigen titer against parainfluenza virus type 3 was detected in one case, while influenza virus antigen was detected in the other two cases.

Heliox for croup in children

Croup is thought to be triggered by a viral infection and is characterised by respiratory distress due to upper airway inflammation and swelling of the subglottic mucosa in children. Mostly it is mild and transient and resolves with supportive care. In moderate to severe cases, treatment with corticosteroids and nebulised epinephrine (adrenaline) is required. Corticosteroids improve symptoms but it takes time for a full effect to be achieved. In the interim, the child is at risk of further deterioration. This may rarely result in respiratory failure necessitating emergency intubation and ventilation. Nebulised epinephrine may result in dose-related adverse effects including tachycardia, arrhythmias and hypertension and its benefit may be short-lived. Helium-oxygen (heliox) inhalation has shown therapeutic benefit in initial treatment of acute respiratory syncytial virus (RSV) bronchiolitis and may prevent morbidity and mortality in ventilated neonates. Heliox has been used during emergency transport of children with severe croup and anecdotal evidence suggests that heliox relieves respiratory distress. To examine the effect of heliox on relieving symptoms and signs of croup, as determined by a croup score (a tool for measuring the severity of croup).To examine the effect of croup on rates of admission or intubation (or both), through comparisons of heliox with placebo or any active intervention(s) in children with croup. We searched CENTRAL 2013, Issue 10, MEDLINE (1950 to October week 5, 2013), EMBASE (1974 to November 2013), CINAHL (1982 to November 2013), Web of Science (1955 to November 2013) and LILACS (1982 to November 2013). In addition, we searched two clinical trials registries: the World Health Organization International Clinical Trials Registry Platform (WHO ICTRP) and clinicaltrials.gov (searched 12 November 2013). Randomised controlled trials (RCTs) and quasi-RCTs comparing the effect of helium-oxygen mixtures with placebo or any active intervention(s) in children with croup. Two review authors independently identified and assessed citations for inclusion. A third review author resolved disagreements. We assessed included trials for allocation concealment, blinding of intervention, completeness of outcome data, selective outcome reporting and other potential sources of bias. We reported mean differences for continuous data and odds ratios for dichotomous data. We descriptively reported data not suitable for statistical analysis. We included three RCTs with a total of 91 participants. One study compared heliox 70%/30% with 30% humidified oxygen administered for 20 minutes in children with mild croup and found no statistically significant differences in the overall change in croup scores between heliox and the comparator. In another study, children with moderate to severe croup were administered intramuscular dexamethasone 0.6 mg/kg and either heliox 70%/30% with one to two doses of nebulised saline, or 100% oxygen with one to two doses of nebulised racaemic epinephrine for three hours. In this study, the heliox group's croup scores improved significantly more at all time points from 90 minutes onwards. However, overall there were no significant differences in croup scores between the groups after four hours using repeated measures analysis. In a third study, children with moderate croup all received one dose of oral dexamethasone 0.3 mg/kg with heliox 70%/30% for 60 minutes in the intervention group and no treatment in the comparator. There was a statistically significant difference in croup scores at 60 minutes in favour of heliox but no significant difference after 120 minutes. It was not possible to pool outcomes because the included studies compared different interventions and reported different outcomes. No adverse events were reported. There is some evidence to suggest a short-term benefit of heliox inhalation in children with moderate to severe croup who have been administered oral or intramuscular dexamethasone. In one study, the benefit appeared to be similar to a combination of 100% oxygen with nebulised epinephrine. In another study there was a slight change in croup scores between heliox and controls, with unclear clinical significance. In another study in mild croup, the benefit of humidified heliox was equivalent to that of 30% humidified oxygen, suggesting that heliox is not indicated in this group of patients provided that 30% oxygen is available. Adequately powered RCTs comparing heliox with standard treatments are needed to further assess the role of heliox in children with moderate to severe croup.

Nebulized epinephrine for croup in children

Croup is a common childhood illness characterized by barky cough, stridor, hoarseness and respiratory distress. Children with severe croup are at risk for intubation. Nebulized epinephrine may prevent intubation. To assess the efficacy (measured by croup scores, rate of intubation and health care utilization such as rate of hospitalization) and safety (frequency and severity of side effects) of nebulized epinephrine versus placebo in children with croup, evaluated in an emergency department (ED) or hospital setting. We searched CENTRAL 2013, Issue 6, MEDLINE (1966 to June week 3, 2013), EMBASE (1980 to July 2013), Web of Science (1974 to July 2013), CINAHL (1982 to July 2013) and Scopus (1996 to July 2013). Randomized controlled trials (RCTs) or quasi-RCTs of children with croup evaluated in an ED or admitted to hospital. Comparisons were: nebulized epinephrine versus placebo, racemic nebulized epinephrine versus L-epinephrine (an isomer) and nebulized epinephrine delivered by intermittent positive pressure breathing (IPPB) versus nebulized epinephrine without IPPB. Primary outcome was change in croup score post-treatment. Secondary outcomes were rate and duration of intubation and hospitalization, croup return visit, parental anxiety and side effects. Two authors independently identified potentially relevant studies by title and abstract (when available) and examined relevant studies using a priori inclusion criteria, followed by methodological quality assessment. One author extracted data while the second checked accuracy. We use the standard methodological procedures expected by the Cochrane Collaboration. Eight studies (225 participants) were included. In general, children included in the studies were young (average age less than two years in the majority of included studies). Severity of croup was described as moderate to severe in all included studies. Six studies took place in the inpatient setting, one in the ED and one setting was not specified. Six of the eight studies were deemed to have a low risk of bias and the risk of bias was unclear in the remaining two studies.Nebulized epinephrine was associated with croup score improvement 30 minutes post-treatment (three RCTs, standardized mean difference (SMD) -0.94; 95% confidence interval (CI) -1.37 to -0.51; I(2) statistic = 0%). This effect was not significant two and six hours post-treatment. Nebulized epinephrine was associated with significantly shorter hospital stay than placebo (one RCT, MD -32.0 hours; 95% CI -59.1 to -4.9). Comparing racemic and L-epinephrine, no difference in croup score was found after 30 minutes (SMD 0.33; 95% CI -0.42 to 1.08). After two hours, L-epinephrine showed significant reduction compared with racemic epinephrine (one RCT, SMD 0.87; 95% CI 0.09 to 1.65). There was no significant difference in croup score between administration of nebulized epinephrine via IPPB versus nebulization alone at 30 minutes (one RCT, SMD -0.14; 95% CI -1.24 to 0.95) or two hours (SMD -0.72; 95% CI -1.86 to 0.42). None of the studies sought or reported data on adverse effects. Nebulized epinephrine is associated with clinically and statistically significant transient reduction of symptoms of croup 30 minutes post-treatment. Evidence does not favor racemic epinephrine or L-epinephrine, or IPPB over simple nebulization.The authors note that data and analyses were limited by the small number of relevant studies and total number of participants and thus most outcomes contained data from very few or even single studies.

Croup in children

Croup develops in more than 80 000 Canadian children each year, making it the second most common cause of respiratory distress in the first decade of life.[1][1],[2][2] It affects boys more than girls (1.4:1) and young children between 6 months and 3 years of age more commonly than younger infants,

Variation and Trends in ED Use of Radiographs for Asthma, Bronchiolitis, and Croup in Children

The objectives were (1) to determine trends in radiograph use in emergency department (ED) care of children with asthma, bronchiolitis, and croup; and (2) to examine the association of patient and hospital factors with variation in radiograph use. A retrospective, cross-sectional study of National Hospital Ambulatory Medical Care Survey data between 1995 and 2009 on radiograph use at ED visits in children aged 2 to 18 years with asthma, aged 3 months to 1 year with bronchiolitis, and aged 3 months to 6 years with croup. Odds ratios (ORs) were calculated and adjusted for all factors studied. The use of radiographs for asthma increased significantly over time (OR: 1.06; 95% confidence interval [CI]: 1.03-1.09; P < .001 for trend) but were unchanged for bronchiolitis and croup. Pediatric-focused EDs had lower use for asthma (OR: 0.44; 95% CI: 0.29-0.68), bronchiolitis (OR: 0.37; 95% CI: 0.23-0.59), and croup (OR: 0.34; 95% CI: 0.17-0.68). Compared with the Northeast region, the Midwest and South had statistically higher use of radiographs for all 3 conditions. The Western region had higher use only for asthma (OR: 1.67; 95% CI: 1.07-2.60), and bronchiolitis (OR: 2.94; 95% CI: 1.48-5.87). No associations were seen for metropolitan statistical area or hospital ownership status. The ED use of radiographs for children with asthma increased significantly from 1995 to 2009. Reversing this trend could result in substantial cost savings and reduced radiation. Pediatric-focused EDs used significantly fewer radiographs for asthma, bronchiolitis, and croup. The translation of practices from pediatric-focused EDs to all EDs could improve performance.

Variation and Trends in ED Use of Radiographs for Asthma, Bronchiolitis, and Croup in Children

Variation and Trends in ED Use of Radiographs for Asthma, Bronchiolitis, and Croup in Children

The management of recurrent croup in children

To review the aetiology, investigation, diagnosis, treatment and clinical outcome of children with recurrent croup. Retrospective case note review of all children with recurrent croup referred to the otolaryngology service at our hospital from November 2002 to March 2011. Ninety children with recurrent croup were identified. Twenty-five children (28 per cent) had anatomical airway abnormalities, of which 16 (18 per cent) demonstrated degrees of subglottic stenosis. Twenty-three children (26 per cent) had positive microlaryngobronchoscopy findings suggestive of reflux. Eleven children were treated for gastroesophageal reflux disease, 10 (91 per cent) of whom responded well to anti-reflux medication (p = 0.006). No cause was identified for 41 (45 per cent) of the children; this was the group most likely to continue having episodes of croup at follow up. One death occurred in this group. Airway anomalies are common in children that present with recurrent croup. Laryngobronchoscopy allows identification of the cause of croup and enables a more accurate prognosis. In the current study, laryngobronchoscopy findings that indicated reflux were predictive of benefit from anti-reflux medications, whereas the clinical presentation of reflux was not. Routine measurement of immunoglobulin E and complement proteins did not appear to be helpful.

CD14 Gene Variants and Their Importance for Childhood Croup, Atopy, and Asthma

Background. The CD14 gene has an important role in the detection of inflammatory provoking pathogens and in the ensuing signaling of the innate immune response. We assessed the role of CD14 C-159T, G-1359T in the expression of asthma, croup, and allergy in Canadian school children of ages 6 to 14 years. Methods. Children attending schools in a rural community participated in a cross-sectional survey of respiratory health. Following consent, we conducted clinical assessments to collect buccal swabs for genotyping and perform skin prick testing (SPT) to determine atopic status. Genotyping and SPT results were available for 533 and 499 children, respectively. Separate multivariable analyses that included both polymorphisms were conducted for each phenotype. Results. The prevalence of asthma, allergy, and croup was 18.6%, 22.4%, and 6.6%, respectively. Children with the T/T variant of CD14 G-1359T were more likely to have physician diagnosed asthma (26.8%). Children with C/C variant of CD14 C-159T had a significantly lower prevalence of croup (2.6%). Haplotype analyses of the two CD14 polymorphisms showed that individuals with the T|T haplotype combination were significantly more likely to have asthma (P = 0.014). Conclusions. In this study, CD14 variants are important for the expression of croup and asthma but not atopy.

Novel polymeric inhibitors of HCoV-NL63

The human coronavirus NL63 is generally classified as a common cold pathogen, though the infection may also result in severe lower respiratory tract diseases, especially in children, patients with underlying disease, and elderly. It has been previously shown that HCoV-NL63 is also one of the most important causes of croup in children. In the current manuscript we developed a set of polymer-based compounds showing prominent anticoronaviral activity. Polymers have been recently considered as promising alternatives to small molecule inhibitors, due to their intrinsic antimicrobial properties and ability to serve as matrices for antimicrobial compounds. Most of the antimicrobial polymers show antibacterial properties, while those with antiviral activity are much less frequent. A cationically modified chitosan derivative, N-(2-hydroxypropyl)-3-trimethylammonium chitosan chloride (HTCC), and hydrophobically-modified HTCC were shown to be potent inhibitors of HCoV-NL63 replication. Furthermore, both compounds showed prominent activity against murine hepatitis virus, suggesting broader anticoronaviral activity.

Commentaries on ‘Nebulized epinephrine for croup in children’

AbstractThese are commentaries on a Cochrane review, published in this issue of EBCH, first published as: Bjornson C, Russell KF, Vandermeer B, Durec T, Klassen TP, Johnson DW. Nebulized epinephrine for croup in children. Cochrane Database of Systematic Reviews 2011, Issue 2. Art. No.: CD006619. DOI: 10.1002/14651858.CD006619.pub2Further information for this Cochrane review is available in this issue of EBCH in the accompanying Summary article. Copyright © 2012 The Cochrane Collaboration. Published by John Wiley &amp; Sons, Ltd. The Cochrane Collaboration

Cochrane Review: Nebulized epinephrine for croup in children

AbstractBackgroundCroup is a common childhood illness characterized by barky cough, stridor, hoarseness and respiratory distress. Children with severe croup are at risk for intubation. Nebulized epinephrine (NE) may prevent intubation.ObjectivesTo evaluate the efficacy and safety of NE in children presenting to emergency department (ED) or admitted to hospital with croup.Search methodsWe searched CENTRAL (The Cochrane Library 2010, Issue 4), containing the Cochrane Acute Respiratory Infections Group's Specialized Register, MEDLINE (1966 to November Week 1, 2010), EMBASE (1980 to November 2010), Web of Science (1974 to November 2010), CINAHL (1982 to November 2010) and Scopus (1996 to November 2010).Selection criteriaRandomized controlled trials (RCTs) or quasi‐RCTs of children with croup evaluated in an ED or admitted to hospital. Comparisons were: NE versus placebo, racemic NE versus L‐epinephrine (an isomer), and NE delivered by intermittent positive pressure breathing (IPPB) versus NE without IPPB. Primary outcome was change in croup score post‐treatment. Secondary outcomes were rate and duration of intubation and hospitalization, croup return visit, parental anxiety and side effects.Data collection and analysisTwo authors independently identified potentially relevant studies by title and abstract (when available) and examined relevant studies using a priori inclusion criteria, followed by methodologic quality assessment. One author extracted data while the second checked accuracy. We performed standard statistical analyses.Main resultsEight studies (225 participants) were included. NE was associated with croup score improvement 30 minutes post‐treatment (three RCTs, standardized mean difference (SMD) ‐0.94; 95% confidence interval (CI) ‐1.37 to ‐0.51; I2 statistic = 0%). This effect was not significant two and six hours post‐treatment. NE was associated with significantly shorter hospital stay than placebo (one RCT, mean difference ‐32.0 hours; 95% CI ‐59.1 to ‐4.9). Comparing racemic and L‐epinephrine, no difference in croup score was found after 30 minutes (SMD 0.33; 95% CI ‐0.42 to 1.08). After two hours, L‐epinephrine showed significant reduction compared with racemic epinephrine (one RCT, SMD 0.87; 95% CI 0.09 to 1.65). There was no significant difference in croup score between administration of NE via IPPB versus nebulization alone at 30 minutes (one RCT, SMD ‐0.14; 95% CI ‐1.24 to 0.95) or two hours (SMD ‐0.72; 95% CI ‐1.86 to 0.42).Authors' conclusionsNE is associated with clinically and statistically significant transient reduction of symptoms of croup 30 minutes post‐treatment. Evidence does not favor racemic epinephrine or LE, or IPPB over simple nebulization.Plain Language SummaryNebulized epinephrine for croup in childrenCroup is a common childhood illness that is usually caused by a viral infection. Symptoms of croup include a hoarse voice, a 'barking' cough and noisy breathing. These symptoms are the result of swelling that occurs in the area of the windpipe (trachea) just below the voice box (larynx). Although most cases of croup are mild and resolve on their own, occasionally the swelling can be severe enough to cause difficulty in breathing. In these children, epinephrine (also called adrenaline) is a medication that is inhaled as a mist to temporarily shrink the swollen area in the trachea.This review looked at trials of inhaled epinephrine for the treatment of children with croup. Compared to no medication, inhaled epinephrine improved croup symptoms in children at 30 minutes following treatment (three studies, 94 children). This treatment effect disappeared two hours after treatment (one study, 20 children). However, children's symptoms did not become worse than prior to treatment. No study measured adverse events. This review is comprised of only eight studies and the number of included children was small (225). Few studies examined similar outcomes, therefore data could often not be pooled and conclusions are based on one or few studies.

Adaptation of Human Parainfluenza Virus to Airway Epithelium Reveals Fusion Properties Required for Growth in Host Tissue

ABSTRACTParamyxoviruses, a family of RNA enveloped viruses that includes human parainfluenza virus type 3 (HPIV3), cause the majority of childhood croup, bronchiolitis, and pneumonia worldwide. Infection starts with host cell receptor binding and fusion of the viral envelope with the cell membrane at the cell surface. The fusion process requires interaction of the two viral surface glycoproteins, the hemagglutinin-neuraminidase (HN) and the fusion protein (F). We have previously shown that viruses with an HN/F pair that is highly fusogenic in monolayers of immortalized cells due to mutations in HN’s secondary sialic acid binding site are growth impaired in differentiated human airway epithelium (HAE) cultures and in vivo. Here we have shown that adaptation of HPIV3 to growth in the lung is determined by specific features of HN and F that are different from those required for growth in cultured immortalized cells. An HPIV3 virus bearing a mutated HN (H552Q), which is fit and fusogenic in immortalized cells but unfit for growth in the lung, evolved into a less-fusogenic but viable virus in differentiated human airway epithelium. Stepwise evolution led to a progressive decrease in efficiency of fusion activation by the HN/F pair, with a mutation in F first decreasing the activation of F by HN and a mutation in HN’s secondary sialic acid binding site decreasing fusion activation further and producing a stable virus. Adaptation of HPIV3 to successful growth in HAE is determined by specific features of HN and F that lead to a less easily activated fusion mechanism.

Classification with discrete and continuous variables via general mixed-data models

We study the problem of classifying an individual into one of several populations based on mixed nominal, continuous, and ordinal data. Specifically, we obtain a classification procedure as an extension to the so-called location linear discriminant function, by specifying a general mixed-data model for the joint distribution of the mixed discrete and continuous variables. We outline methods for estimating misclassification error rates. Results of simulations of the performance of proposed classification rules in various settings vis-à-vis a robust mixed-data discrimination method are reported as well. We give an example utilizing data on croup in children.

The Cochrane Database of Systematic Reviews – Issue 2 2011

The Cochrane Database of Systematic Reviews – Issue 2 2011

Stridor at night

AbstractDr Cochrane is a unique self‐learning experience—the integration of Cochrane evidence with a quirky fictional story and multiple‐choice questions provides readers with the opportunity to explore and understand the applicability of a Cochrane Review or Overview in a new way. In this series of fictional clinical vignettes, Dr Cochrane travels across time from the past century to the present day, to solve clinical problems using evidence from Cochrane Reviews. Read the associated article and/or listen to the Evidence‐Based Child Health podcast available online at www.cochrane.org/podcasts/and then test your knowledge with six multiple choice questions. You can find the answers to the questions on page 276.Based on:Candice Bjornson, Kelly Russell, Michelle Foisy, David W Johnson The Cochrane Library and the Treatment of Croup in Children: An Overview of Reviews.Hartling L, Scott S, Pandya R, et al.: Storytelling as a communication tool for health consumers: development of an intervention for parents of children with croup. Stories to communicate health information. BMC Pediatrics 2010 10:64. Copyright © 2011 The Cochrane Collaboration. Published by John Wiley &amp; Sons, Ltd. The Cochrane Collaboration

The Cochrane Library and the treatment of croup in children: an overview of reviews

AbstractBackgroundCroup is an illness characterized by barky cough, stridor, hoarseness, and occasionally respiratory distress. It is a relatively mild and short‐lived illness for the majority of children. However, a small proportion of children have moderate to severe symptoms and are at risk of hospital admission, and in the most severe cases, intubation.ObjectiveTo synthesize the evidence currently in The Cochrane Database of Systematic Reviews (CDSR) related to the clinical effectiveness and applicability of four treatments for croup: glucocorticoids, epinephrine, heliox and humidified air.MethodsThe CDSR was searched for all systematic reviews containing the term ‘croup’ in the title. Pharmacologic and nonpharmacologic interventions for the treatment of croup in children were included. Data were extracted, compiled into tables and synthesized using qualitative and quantitative methods.Main ResultsFour reviews examining the treatment of croup were included in this overview. Children treated with epinephrine vs placebo had a significantly lower croup score at 30 min (SMD: − 0.94; 95% CI: − 1.37, − 0.51), and children treated with glucocorticoids vs placebo had significantly lower croup scores at both 6 h and 12 h (SMD: − 0.59; 95% CI: − 0.83, − 0.35 and SMD: − 0.65; 95% CI: − 1.03, − 0.27). Glucocorticoids vs placebo also significantly reduced inpatient length of stay (MD: − 10.33; 95% CI: − 17.33, − 3.36) and risk of return visits and/or re‐admissions (RR: 0.49; 95% CI: 0.34, 0.71). Neither humidified air nor heliox were associated with significant reductions in croup score; however, there is a paucity of evidence examining treatment with heliox.Author's ConclusionsGlucocorticoids are effective for children with mild croup, and both nebulized epinephrine and glucocorticoids are effective treatments for children presenting with moderate to severe croup that is associated with respiratory distress. There is insufficient evidence to determine the effectiveness of heliox, and there is sufficient evidence to suggest that humidified air is not effective in the treatment of croup. Copyright © 2010 The Cochrane Collaboration. Published by John Wiley &amp; Sons, Ltd. The Cochrane Collaboration

Chronic cough: a natural (and parental) disaster

AbstractThe second in this series of Dr Cochrane clinical vignettes is based upon an overview of Cochrane Reviews that was published in the previous issue of Evidence‐Based Child Health: Russell K, Chang AB, Foisy M, Thomson D and Williams K: The Cochrane Library and the Treatment of Chronic Cough in Children: An Overview of Reviews: Evid.‐Based Child Health 2010, 5: 1196–1205.Dr Cochrane is a unique self‐learning experience—the integration of Cochrane evidence with a quirky fictional story and multiple‐choice questions provides readers with the opportunity to explore and understand the applicability of a Cochrane Review or Overview in a new way.In this series of fictional clinical vignettes, Dr Cochrane travels across time from the past century to the present day, to solve clinical problems using evidence from Cochrane Reviews. Read the associated article and/or listen to the Evidence‐Based Child‐Health podcast available online at www.cochrane.org/podcasts/ and then test your knowledge with six multiple choice questions. You can find the answers to the questions in this issue on page 2007.In the next issue of Evidence‐based Child Health, Dr Cochrane explores the evidence for croup, based upon the Cochrane Overview available in this issue (Bjornson C, Russell K, Foisy M and Johnson DW: The Cochrane Library and the Treatment of Croup in Children: An Overview of Reviews. Evid.‐Based Child Health 2010, 5, 1555–1565). Copyright © 2010 The Cochrane Collaboration. Published by John Wiley &amp; Sons, Ltd. The Cochrane Collaboration