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- Diagnosis and management of croup in children
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What are you looking for? Search for articles. The findings of this large, high quality review reinforce current recommendations and practice with a moderate degree of certainty. They suggest that corticosteroids rapidly reduce symptoms of croup in children, within about 2 hours and that the effect lasts for at least 24 hours.
The findings may support earlier escalation of therapy following a lack of response at 2 hours. Glucocorticoids for croup in children. Cochrane Database Syst Rev. NHS website. London: Department of Health and Social Care; updated Clinical Knowledge Summary.
View commentaries on this research This is a plain English summary of an original research article Corticosteroids reduce symptoms of croup in children within two hours and continue to do so for at least 24 hours. Why was this study needed? What did this study do? What did it find? This article provides pediatricians and other pediatric healthcare providers with quick reference to the diagnosis and management of croup.
The goal is to help pediatricians accurately diagnose and treat these children as well as educate their parents on the symptoms of the illness to help them know when to call their physician or when a visit to the ED is warranted. Symptoms of croup can be similar to other respiratory diseases, so making the differential diagnosis is important to both treat appropriately and avoid unnecessary treatment. Most cases of croup are from a viral infection called laryngotracheitis or are spasmodic called recurrent croup , although other conditions can mimic the symptoms of croup and need to be considered in making the differential diagnosis Table 1.
This article will focus on the diagnosis and treatment of croup, however pediatricians should be aware of recurrent croup and the potential for an underlying condition that may be masked by the persistence of croup symptoms Table 2. Croup related to a viral infection is most frequently caused by parainfluenza virus type 1 and less commonly, type 3. Diagnosis is based primarily on history and physical examination. Most cases of viral croup are self-limiting and symptoms resolve on their own.
This is followed by a barking cough and mild to severe degrees of respiratory distress, including nasal flaring, stridor, and respiratory retractions. Read more: Using Iggy and the Inhalers to teach asthma medication compliance. The severity of respiratory distress is key to an accurate differential diagnosis as well as appropriate management, so assessment of the degree of airway obstruction is critical in the initial assessment.
For children who present with severe respiratory symptoms not from viral croup, other diagnostic imaging and lab work may be helpful along with the history and physical examination to make the differential diagnosis Table 5. A single dose of a systemic corticosteroid is currently recommended as treatment of choice for croup, even in children with mild disease. A single dose of nebulized budesonide 2 mg is indicated based on the current best evidence for children with mild to moderate or moderate to severe croup who are vomiting or unable to take oral medications.
Oral corticosteroids are preferred when tolerated, however, because they are more effective, convenient, and less expensive. Still unclear and needing further investigation is the optimal dose range of dexamethasone and whether repeated doses of corticosteroids provide additional benefit in children with severe croup. A randomized comparison of dexamethasone 0. Parker, C. Oral dexamethasone in the treatment of croup: 0. Efficacy of a small single dose of oral dexamethasone for outpatient croup: a double blind placebo controlled clinical trial.
Sixteen years of croup in a Western Australian teaching hospital: effects of routine steroid treatment. A randomised double blinded trial. Emergency Medicine Australasia. Australian Edition. Back to top.
Barking cough No stridor at rest No sternal recession or tracheal tug Normal behaviour. Dexamethasone 1. All croup presentations should be treated with oral dexamethasone.
Prednisolone 2. If oral dexamethasone is not available. Rarely required. For severe cases of croup PCC candidates. Doses of 5mL can be given undiluted.
To be given with oxygen at 8 litres per minute via nebuliser.
Go to whole of WA Government Search. They are not strict protocols, and they do not replace the judgement of a senior clinician.
Clinical common-sense should be applied at all times. These clinical guidelines should never be relied on as a substitute for proper assessment with respect to the particular circumstances of each case and the needs of each patient. Clinicians should also consider the local skill level available and their local area policies before following any guideline. Click on the image to download a high resolution PDF. Severe croup is treated as above with high flow oxygen and nebulised adrenaline.
Adrenaline can be repeated 15 minutely as required. Moderate croup will need observation e. ED short stay unit until there is no stridor at rest. All children requiring an adrenaline nebuliser should be observed for at least 3 hours. Mild croup will not need observation and can be discharged home, after administration of oral steroid. Oxygen delivery at less than 8 litres per minute will not drive the nebuliser adequately.
This document can be made available in alternative formats on request for a person with a disability. Skip to main content Skip to navigation Site map Accessibility Contact us. Search this site. Search all sites. Definition Croup laryngotracheobronchitis is an upper respiratory illness characterised by a hoarse voice, barking cough, and stridor.
The clinical symptoms are a result of inflammation and narrowing of the upper airway larynx, trachea and bronchi. Background Croup is most commonly caused by the Parainfluenza virus, but a variety of respiratory viruses may be responsible Symptoms are usually more prominent at night Most cases are mild and do not require admission Severe cases can be life-threatening due to potential airway compromise.
Assessment Do not upset the child — this will exacerbate the symptoms The severity of the stridor is not an indication of the severity of croup History Ask about the onset and duration of symptoms: Coryza Cough Stridor Increased work of breathing.
Possibility of inhaled foreign body or anaphylaxis Past history — e. Examination It is important not to exacerbate the symptoms by upsetting the child — keep your assessment short and as non-invasive as possible. Keep the child in their most comfortable position e. Work of breathing: Degree mild, moderate or severe Recession sternal, intercostal, subcostal, tracheal tug.
Monitor for signs of impending respiratory exhaustion. Differential diagnoses Underlying congenital abnormality eg: laryngomalacia, tracheomalacia Inhaled foreign body Anaphylaxis Epiglottitis Bacterial tracheitis. Management All children who present to Emergency Department with croup should receive corticosteroids Additional treatments depend on the severity and may include nebulised adrenaline See Croup Management Flowchart.
Croup Management Flowchart Click on the image to download a high resolution PDF Resuscitation Life threatening croup: Transfer the child to the Resuscitation Room, activate the resuscitation team Give nebulised adrenaline internal WA Health only immediately0.
Initial management Severe croup is treated as above with high flow oxygen and nebulised adrenaline. Medications Corticoteroids Steroids start working by 30 minutes and reduce time in hospital, transfers to PCC, the chances of intubation for inpatients, and also reduce the likelihood of relapse after discharge home. Steroid therapy is extremely successful in treating stridor, but does not resolve the underlying viral symptoms.
A single dose of steroid is usually all that is required in mild to moderate croup. Medication Dose Route Treatment Dexamethasone 1 0. Dexamethasone 1 0. Can give if oral steroids are not tolerated e. Adrenaline The effect of nebulised adrenaline is short lived and is thought not to change the natural history of croup. It may be repeated after 15 minutes if necessary. Children receiving adrenaline need to be observed for a minimum of 3 hours afterwards. Oxygen delivery at less than 8 litres per minute will not drive the nebuliser adequately Admission criteria As a 'rule of thumb' children without stridor do not need to be admitted This decision would be influenced by the distance parents live from the hospital, the reported severity of symptoms at home and past history of severe croup.
Infection control Children presenting to hospital with croup should be managed with droplet precautions. Discharge criteria The child must meet all of the following criteria: Clinically improved Steroids received No stridor at rest No other clinical or social concerns. Nursing Minimal nursing intervention is encouraged to avoid distressing the child and increasing respiratory distress.
Patients should remain in a position of comfort. Children with croup require close observation. Record baseline observations: heart rate, respiratory rate, oxygen saturations and temperature on the Observation and Response Tool and document additional observations on the Clinical Comments chart. The presence or absence of the following clinical features should be assessed and documented: stridor barking cough degree and type of recession i.
Observations should be recorded at least hourly whilst in the emergency department. Any significant changes should be reported immediately to the medical team. Oxygen saturations and ECG monitoring is recommended if adrenaline is given. Before applying consider whether the risk of distress negates the accuracy of monitoring.
Assessment and management of viral croup in children: Viral croup. Prescriber 27, 32— Bjornson, C. Nebulized epinephrine for croup in children.
Cochrane Database Syst. Chub-Uppakarn, S. A randomized comparison of dexamethasone 0. Parker, C. Oral dexamethasone in the treatment of croup: 0. Efficacy of a small single dose of oral dexamethasone for outpatient croup: a double blind placebo controlled clinical trial.
Sixteen years of croup in a Western Australian teaching hospital: effects of routine steroid treatment. A randomised double blinded trial. Emergency Medicine Australasia. Australian Edition. Back to top. Barking cough No stridor at rest No sternal recession or tracheal tug Normal behaviour. Dexamethasone 1. All croup presentations should be treated with oral dexamethasone.
Prednisolone 2. If oral dexamethasone is not available. Rarely required. For severe cases of croup PCC candidates. Doses of 5mL can be given undiluted.
To be given with oxygen at 8 litres per minute via nebuliser.
Corticosteroids may be warranted even for those children who present with mild symptoms. An updated Cochrane Review reported that. Corticosteroids reduce symptoms of croup in children within two hours and continue to do so for at least 24 hours. mg/kg, IM, Rarely required. Can give if oral steroids are. There are two types of steroid medication being used for croup: dexamethasone and prednisolone. Both of these are taken by mouth as a small. Prednisone treated croup equally effectively compared with dexamethasone. Commentary. Since the late s, multiple studies have demonstrated. What are the implications? Find a provider.A common childhood upper-airway disorder, croup is among several respiratory illnesses that require pediatricians and other healthcare providers to make an accurate differential diagnosis to ensure appropriate treatment. It occurs most commonly in children aged between 6 months and 3 years and during the late autumn months, but sporadic cases can also occur any time of year and in older children. Recommended: 'Red flags' for chronic cough.
Although most cases of croup resolve on their own, children with even mild disease are now routinely treated with corticosteroids and those with more moderate to severe disease with immediate nebulized adrenaline. This article provides pediatricians and other pediatric healthcare providers with quick reference to the diagnosis and management of croup. The goal is to help pediatricians accurately diagnose and treat these children as well as educate their parents on the symptoms of the illness to help them know when to call their physician or when a visit to the ED is warranted.
Symptoms of croup can be similar to other respiratory diseases, so making the differential diagnosis is important to both treat appropriately and avoid unnecessary treatment. Most cases of croup are from a viral infection called laryngotracheitis or are spasmodic called recurrent croup , although other conditions can mimic the symptoms of croup and need to be considered in making the differential diagnosis Table 1.
This article will focus on the diagnosis and treatment of croup, however pediatricians should be aware of recurrent croup and the potential for an underlying condition that may be masked by the persistence of croup symptoms Table 2. Croup related to a viral infection is most frequently caused by parainfluenza virus type 1 and less commonly, type 3.
Diagnosis is based primarily on history and physical examination. Most cases of viral croup are self-limiting and symptoms resolve on their own.
This is followed by a barking cough and mild to severe degrees of respiratory distress, including nasal flaring, stridor, and respiratory retractions. Read more: Using Iggy and the Inhalers to teach asthma medication compliance. The severity of respiratory distress is key to an accurate differential diagnosis as well as appropriate management, so assessment of the degree of airway obstruction is critical in the initial assessment. For children who present with severe respiratory symptoms not from viral croup, other diagnostic imaging and lab work may be helpful along with the history and physical examination to make the differential diagnosis Table 5.
A single dose of a systemic corticosteroid is currently recommended as treatment of choice for croup, even in children with mild disease. A single dose of nebulized budesonide 2 mg is indicated based on the current best evidence for children with mild to moderate or moderate to severe croup who are vomiting or unable to take oral medications. Oral corticosteroids are preferred when tolerated, however, because they are more effective, convenient, and less expensive.
Still unclear and needing further investigation is the optimal dose range of dexamethasone and whether repeated doses of corticosteroids provide additional benefit in children with severe croup. More: A new model for hospital-based pediatric care. For children with moderate to severe croup, the addition of nebulized epinephrine is indicated by the current best evidence. Although the optimal dose of nebulized epinephrine in this setting is unknown, a dose of 3 ml of L-epinephrine, solution, has been recommended.
Treatments that are not supported by the evidence, and therefore not recommended, include humidification therapy and Heliox. A number of algorithms have been proposed to facilitate treatment decisions based on the severity of croup. Figure 1 and Figure 2 provide examples of treatment algorithms based on recent systematic reviews of the literature.
To date, good evidence is lacking on a standard to employ to admit a child to the hospital or to know when it is safe to discharge them from the ED. Croup is a common childhood upper-airway disorder most frequently caused by viral infection and occurring most often in children aged between 6 months and 3 years. Because symptoms can mimic symptoms of other disorders, a differential diagnosis considering the degree of airway obstruction is critical to ensure appropriate management.
Standard treatment for all cases of croup regardless of severity is treatment with a single dose of a corticosteroid, with the addition of nebulized adrenaline for children with more moderate to severe disease. Most children with croup will not need to be seen in the ED or need hospitalization. However, recognizing the signs and symptoms of more acute illness that does require hospitalization is important to reduce the number of unnecessary ED visits and hospitalizations.
Toward Optimized Practice Program. Guideline for the diagnosis and management of croup. Edmonton, Alberta: Alberta Medical Association. Revised January Accessed February 23, Croup: an overview. Am Fam Physician. Viral croup: diagnosis and a treatment algorithm. Pediatr Pulmonol. Fifteen-minute consultation: structured approach to management of a child with recurrent croup.
Respiratory viruses in laryngeal croup of young children J Pediatr. Erratum in: J Pediatr. Malhotra A, Krilov LR. Viral croup. Pediatr Rev. Erratum in: Pediatr Rev. Rajapaksa S, Starr M. Croup-assessment and management. Aust Fam Physician. Evidence based guideline for the management of croup. Everard ML. Acute bronchiolitis and croup. Pediatr Clin North Am. Ms Nierengarten, a medical writer in St. Paul, Minnesota, has over 25 years of medical writing experience, coauthoring articles for Lancet Oncology , Lancet Neurology , Lancet Infectious Diseases , and Medscape.
She has nothing to disclose in regard to affiliations with or financial interests in any organizations that may have an interest in any part of this article. Diagnosis and management of croup in children. March 1, Etiology and diagnosis Symptoms of croup can be similar to other respiratory diseases, so making the differential diagnosis is important to both treat appropriately and avoid unnecessary treatment.
NEXT: Further ways to diagnose croup Croup related to a viral infection is most frequently caused by parainfluenza virus type 1 and less commonly, type 3. Read more: Using Iggy and the Inhalers to teach asthma medication compliance The severity of respiratory distress is key to an accurate differential diagnosis as well as appropriate management, so assessment of the degree of airway obstruction is critical in the initial assessment.
Croup in children. Cherry JD, Clinical practice. N Engl J Med.
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