Clinical Notes : Paediatrics
4. Croup

Incidence
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Laryngotracheitis, more commonly known as croup, is common in younger children, usually mild and self-limiting.
Etiology
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Parainfluenza viruses account for around 80% of cases
Diagnosis
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Commonly seen from 6 months to 3 years, but can present at any age
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Seal-like barking cough and stridor are the major features
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Respiratory distress in more severe cases; hoarse voice
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Fever may be present, but not always.
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Often associated with prodromal non-specific viral URTI symptoms
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Classically worse at night
Croup cough
Seal-like barking cough.

Assessment of severity
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Mild
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Occasional cough, no stridor or respiratory distress, child happy, plays, eats and drinks
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Moderate
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Frequent cough, audible stridor, suprasternal/sternal wall retraction, no/little distress
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Severe
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Frequent cough, prominent stridor, marked recession, significant distress/agitation
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Life threatening
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Change in mental state (lethargy, decreased consciousness), pallor, dusky appearance, tachycardia – in impending respiratory failure cough/stridor/recession may reduce or stop
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Stridor
A loud, high-pitched sound wheezing sound heard during inspiration but may also occur throughout the respiratory cycle.
Often heard without a stethoscope.

Differential Diagnosis – rare but serious
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Acute epiglottis
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Life threatening emergency, differentiated by presence of drooling and absence of cough
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Often septic, grey
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Uncommon now due to early Hib vax
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If suspected do not examine or panic child/parents – arrange immediate admission
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Bacterial tracheitis, peritonsillar abscess, retropharyngeal abscess or diphtheria
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Non-infectious causes include foreign body and angioedema amongst others
Indications for hospital admission
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Any serious differential diagnosis
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Moderate, severe or life threatening croup
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High risk factors
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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
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Mild croup can be managed at home
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All children should be given a single dose of oral dexamethasone (available in Ireland as 2mg/5ml solution and 2 mg tablet)
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0.15mg/kg body weight
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Wait 30 minutes then assess again
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If unable to get accurate weight then estimate
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1.5-2mg average sized child aged 12-15 months,
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2-3mg aged 3-4 years
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If not available then oral prednisolone (1-2mg/kg) second line option
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Prescribe for 3 days course
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nebulised budesonide is also effective
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2mg single dose via nebulizer or respules; or 2 X 1 mg doses at 30 min interval
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No adverse events have been associated with the use of corticosteroids in children + croup
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PRN antipyretics for fever if child distressed
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Advise antibiotics are not required and decongestants/beta agonists are not effective
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Humidified air (i.e. steam) does not improve symptoms/outcomes and is no longer recommended
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Appropriate safety netting in case of deterioration
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Croup usually resolves in 48hours and is followed by more classic URTI symptoms
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Less commonly symptoms can last for >1 week
Recurrent croup
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Be vigilant and consider other causes with more than 2 episodes of croup per year especially if < 6 weeks or >3 years.
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Consider referral to ENT for assessment

Defendi GL
Croup Treatment & Management
Medscape
October 2018
Benson BE, Baredes S, Schwartz RA.
Stridor.
Medscape
March 2018
Acute management of croup in the emergency department
Canadian Paediatric Association
May 2017

The following are available in Ireland :
Oral prednisolone (Deltacortil enteric, Prednesol)
Nebulised budenoside (Pulmicort)
Oral dexamethasone solution (Dexsol)
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