Clinical Notes : Paediatrics

4. Croup

Incidence

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

 Etiology

  • Parainfluenza viruses account for around 80% of cases

 

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

 
 
 
 

Croup cough

Seal-like barking cough.

Croup cough -
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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

Stridor

A loud, high-pitched sound wheezing sound heard during inspiration but may also occur throughout the respiratory cycle.

Often heard without a stethoscope.

Stridor -
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 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

 

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

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

 

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

 

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

 
 
 
 
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Defendi GL

Croup Treatment & Management

Medscape 

October 2018

Access

Benson BE, Baredes S, Schwartz RA.

Stridor.

Medscape

March 2018

Access

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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