Clinical Notes : Paediatrics

4. Croup

Incidence

Etiology

Diagnosis

Assessment of Severity

Differential Diagnosis

Indications for Hospital Admission

Management

Recurrent Croup

- References -

- CPD Quiz -

Incidence

• Laryngotracheitis, more commonly known as croup, is common in younger children, usually mild and self-limiting.

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 Etiology

• Parainfluenza viruses account for around 80% of cases

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Diagnosis

• Commonly seen from 6 months to 3 years, but can present at any age

• Seal-like barking cough and stridor are the major features

• Respiratory distress in more severe cases; hoarse voice

• Fever may be present, but not always.

• Often associated with prodromal non-specific viral URTI symptoms

• Classically worse at night

Assessment of severity

• Mild

  • Occasional cough, no stridor or respiratory distress, child happy, plays, eats and drinks

•       Moderate   

  • Frequent cough, audible stridor, suprasternal/sternal wall retraction, no/little distress

• Severe

  • Frequent cough, prominent stridor, marked recession, significant distress/agitation

• Life threatening

  • Change in mental state (lethargy, decreased consciousness), pallor, dusky appearance, tachycardia – in impending respiratory failure cough/stridor/recession may reduce or stop

 Differential Diagnosis – rare but serious

• Acute epiglottis

• Life threatening emergency, differentiated by presence of drooling and absence of cough

• Often septic, grey

• Uncommon now due to early Hib vax

• If suspected do not examine or panic child/parents –  arrange immediate admission

• Bacterial tracheitis, peritonsillar abscess, retropharyngeal abscess or diphtheria

• Non-infectious causes include foreign body and angioedema amongst others

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Indications for hospital admission

• Any serious differential diagnosis

• Moderate, severe or life threatening croup

• High risk factors

• History of severe obstruction, airways abnormalities, immunocompromised , <6 months old, inadequate fluid intake, severe parental anxiety, logistics – remote home etc

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Admission rates in Ireland peak late Autumn, between September and December.

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Management

• Mild croup can be managed at home

• All children should be given a single dose of oral dexamethasone (available in Ireland as 2mg/5ml solution and 2 mg tablet)

• 0.15mg/kg body weight

• Wait 30 minutes then assess again

• If unable to get accurate weight then estimate

• 1.5-2mg average sized child aged 12-15 months,

• 2-3mg aged 3­-4 years

• If not available then oral prednisolone (1-2mg/kg) second line option

• Prescribe for 3 days course

• nebulised budesonide is also effective

• 2mg single dose via nebulizer or respules; or 2 X 1 mg doses at 30 min interval

• No adverse events have been associated with the use of corticosteroids in children + croup

• PRN antipyretics for fever if child distressed

• Advise antibiotics are not required and decongestants/beta agonists are not effective

• Humidified air (i.e. steam) does not improve symptoms/outcomes and is no longer recommended

• Appropriate safety netting in case of deterioration

• Croup usually resolves in 48hours and is followed by more classic URTI symptoms

• Less commonly symptoms can last for >1 week

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Recurrent croup

• Be vigilant and consider other causes with more than 2 episodes of croup per year especially if < 6 weeks or >3 years.

• Consider referral to ENT for assessment

Defendi GL

Croup Treatment & Management

Medscape 

October 2018

​Access

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Benson BE, Baredes S, Schwartz RA.

Stridor.

Medscape

March 2018

​Access

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Acute management of croup in the emergency department

Canadian Paediatric Association

May 2017

Access

The following are available in Ireland :

Oral prednisolone (Deltacortil enteric, Prednesol)

Nebulised budenoside (Pulmicort)

Oral dexamethasone solution (Dexsol)

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