What are the diagnosis and management of croup in a pediatric patient?

Croup: Diagnosis and Management

Clinical Presentation and Diagnosis

Croup is a clinical diagnosis characterized by barking cough, inspiratory stridor, and respiratory distress in children aged 6 months to 6 years, typically preceded by upper respiratory symptoms. 1

Key Diagnostic Features

• Barking "seal-like" cough with low-grade fever and coryza 1
• Inspiratory stridor that worsens with agitation 2
• Median age of presentation is 23 months, with male predominance (63%) 3
• Parainfluenza viruses (types 1-3) are the most common causative agents, though identifying the specific pathogen does not alter treatment 3, 1

Clinical Assessment Priorities

Immediately assess severity indicators including: 3

• Ability to speak/cry normally
• Respiratory rate and heart rate
• Presence of stridor at rest
• Use of accessory muscles
• Oxygen saturation
• Life-threatening signs: silent chest, cyanosis, fatigue/exhaustion, or poor respiratory effort

Diagnostic Pitfalls to Avoid

• Radiographic studies are generally unnecessary and should be avoided unless there is concern for an alternative diagnosis 4, 3
• Always consider alternative diagnoses including bacterial tracheitis, epiglottitis, foreign body aspiration, retropharyngeal abscess, and peritonsillar abscess, particularly in patients who fail to respond to standard treatment 3
• Never perform blind finger sweeps in suspected foreign body aspiration, as this may push objects further into the pharynx 3

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Treatment Algorithm

Mild Croup

All children with croup, regardless of severity, should receive oral corticosteroids immediately. 5, 4

• Dexamethasone 0.15-0.6 mg/kg orally (maximum 10-12 mg) as a single dose 4, 3
• Alternative: Prednisolone 1-2 mg/kg (maximum 40 mg) if dexamethasone unavailable 3
• Observe for 2-3 hours to ensure symptoms are improving 5
• No nebulized treatments needed for mild cases 5

Moderate to Severe Croup

For children with stridor at rest or significant respiratory distress: 4, 3

• Oral dexamethasone 0.15-0.6 mg/kg (maximum 10-12 mg) 4
• Add nebulized epinephrine 0.5 ml/kg of 1:1000 solution (maximum 5 ml) 5, 4
• Alternative: Nebulized budesonide 2 mg is equally effective as oral dexamethasone when oral administration is not feasible 4

Critical Management Considerations for Nebulized Epinephrine

• Effects last only 1-2 hours with risk of rebound symptoms 5, 3
• Observe for at least 2 hours after the last dose to assess for symptom rebound 5, 3
• Never use in outpatient settings where immediate return is not feasible or in children shortly to be discharged 5, 4, 3
• Never discharge within 2 hours of nebulized epinephrine administration 3

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Hospitalization Criteria

The most recent American Academy of Pediatrics guidelines recommend considering hospitalization after 3 doses of nebulized epinephrine rather than the traditional 2 doses ("3 is the new 2" approach). 6, 5, 4

This evidence-based change:

• Reduces hospitalization rates by 37% without increasing revisits or readmissions 6, 4, 3
• Decreased admission rates from 8.7% to 5.5% in implementation studies 6
• Admission rate in patients receiving ≤2 epinephrine doses dropped from 6.3% to 1.7% (72% relative decrease) 6

Additional Admission Criteria

• Oxygen saturation <92% 4, 3
• Age <18 months 4, 3
• Respiratory rate >70 breaths/min 4, 3
• Persistent stridor at rest despite treatment 5
• Persistent difficulty in breathing 4

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Supportive Care

Oxygen Therapy

• Administer oxygen to maintain saturation ≥94% via nasal cannula, head box, or face mask 4, 3
• Agitation may indicate hypoxemia requiring oxygen 3
• Monitor oxygen saturation at least every 4 hours for patients on oxygen therapy 3

Positioning

• For children under 2 years, use neutral head position with a roll under the shoulders to optimize airway patency 3

Comfort Measures

• Antipyretics can be used to keep the child comfortable 4, 3
• Minimal handling may reduce metabolic and oxygen requirements 4, 3

Ineffective Therapies to Avoid

• Humidified or cold air lacks evidence of benefit 3, 1, 7
• Chest physiotherapy is not beneficial and should not be performed 3
• Antibiotics should not be used routinely, as croup is typically viral 4
• Normal saline nebulization is not recommended as primary treatment 5

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Discharge Criteria

Children may be discharged when: 4

• Resolution of stridor at rest
• Minimal or no respiratory distress
• Adequate oral intake
• Parents able to recognize worsening symptoms and return if needed
• Reliable family able to monitor and return if worsening 3

Discharge Instructions

• Review by general practitioner if deteriorating or not improving after 48 hours 4, 3
• Provide families with information on managing fever, preventing dehydration, and identifying signs of deterioration 3
• Ensure clear return precautions are provided 4

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Special Considerations

Recurrent Croup

Consider asthma as a differential diagnosis in children with recurrent episodes, especially if: 3

• Cough worsens at night
• Episodes triggered by exercise or irritants
• Family history of asthma or atopy
• Presence of atopic dermatitis
• Consider prophylactic inhaled corticosteroids in these cases

When to Perform Bronchoscopy

Flexible bronchoscopy should be performed in cases of: 3

• Severe or persistent symptoms not responding to standard treatment
• Associated hoarseness
• Oxygen desaturation or apnea
• Atypical presentation raising concern for anatomic abnormality
• Up to 68% of infants with stridor have concomitant lower airway abnormalities requiring complete airway evaluation

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Common Pitfalls Summary

• Admitting after only 1-2 doses of epinephrine when a third dose could be safely administered in the ED 4
• Discharging too early after nebulized epinephrine (before 2-hour observation) 5, 4, 3
• Failing to administer corticosteroids in mild cases 5, 4
• Using epinephrine in outpatient settings without adequate observation 5, 4
• Not providing clear return precautions to parents 4
• Ordering unnecessary neck radiographs 6, 4, 3