What should be included in the initial office examination for a child with recurrent croup?

Office Examination for Recurrent Croup in Children

When a child presents with recurrent croup (≥2 episodes per year), this should be considered a symptom of an underlying structural or inflammatory airway abnormality requiring systematic evaluation, not just repeated treatment of acute episodes. 1

Initial Clinical Assessment

History Taking

• Document the frequency and pattern of episodes: Confirm truly recurrent croup (≥2 episodes per year) versus isolated events 1
• Characterize the cough: Classic barky or "seal-like" cough, presence of inspiratory stridor, hoarseness, and degree of respiratory distress 2, 3
• Identify triggers: Viral prodrome (typical viral croup) versus sudden onset without preceding illness (spasmodic croup) 1
• Assess severity of past episodes: History of hospitalization, need for racemic epinephrine, intubation, or ICU admission 4
• Screen for feeding difficulties: Coughing with feeding suggests aspiration or structural abnormality requiring urgent investigation 4
• Environmental exposures: Tobacco smoke and other pollutants that may exacerbate symptoms 4

Physical Examination Focus

• Airway assessment: Listen for stridor at rest (indicates moderate-severe obstruction), quality of voice/cry, presence of hoarseness 2, 3
• Work of breathing: Chest wall indrawing, use of accessory muscles, nasal flaring, respiratory rate 2, 5
• Look for specific cough pointers that mandate further workup 4:
  • Digital clubbing (suggests chronic lung disease or bronchiectasis)
  • Failure to thrive (suggests chronic aspiration, cardiac disease, or other systemic pathology)
  • Abnormal cry or voice quality between episodes (suggests vocal cord pathology or laryngeal abnormality)
• Cardiac examination: Murmurs or signs of congestive heart failure (vascular compression of airway) 4
• General appearance: Signs of toxicity, exhaustion, cyanosis, or agitation 3

Mandatory Investigations for Recurrent Croup

Imaging

• Chest radiograph: Recommended to identify structural abnormalities, vascular compression, masses, or alternative diagnoses 4
• Neck radiograph: Generally not indicated unless alternative diagnosis suspected (epiglottitis, retropharyngeal abscess) 4

Airway Endoscopy

Flexible laryngoscopy/bronchoscopy is the definitive diagnostic test for recurrent croup and should be strongly considered, as 40% of patients will have identifiable structural abnormalities. 1

Indications for direct laryngoscopy/bronchoscopy 4, 1:

• Persistent or severe stridor between episodes
• Stridor associated with hoarseness
• Stridor leading to oxygen desaturation or apnea
• Any child with recurrent croup where underlying structural cause is suspected
• Failure to respond to standard croup therapy

Common findings on endoscopy in recurrent croup patients 4:

• Laryngomalacia (most common congenital laryngeal anomaly)
• Subglottic stenosis or webs
• Tracheomalacia or bronchomalacia
• Vocal cord paralysis (third most common congenital laryngeal anomaly)
• Vascular compression of airway
• Hemangiomas or other masses

Additional Testing (Individualized Based on Clinical Findings)

• Spirometry: If child ≥6 years old and able to perform reliably, to assess for asthma or reversible airway obstruction 4
• Sweat test and immune workup: If recurrent infections beyond just croup, or failure to thrive 4
• Barium swallow or video fluoroscopy: If aspiration suspected (coughing with feeds, recurrent pneumonia) 4

Critical Differential Diagnoses to Exclude

During the office exam, actively rule out 2, 3, 5:

• Epiglottitis: Toxic appearance, drooling, tripod positioning, high fever (medical emergency)
• Foreign body aspiration: Sudden onset, unilateral wheeze, history of choking episode
• Bacterial tracheitis: Toxic appearance, high fever, not responding to standard croup therapy
• Retropharyngeal or peritonsillar abscess: Fever, dysphagia, neck stiffness
• Angioedema: Rapid onset, history of allergies or ACE inhibitor exposure

Common Pitfalls to Avoid

• Do not assume all recurrent episodes are simple viral croup without investigating for structural abnormalities—60% of patients undergoing bronchoscopy for recurrent croup have normal airways, but 40% have identifiable pathology requiring specific management 6, 1
• Do not diagnose asthma based on recurrent croup alone—while the presentation may mimic asthma, true recurrent croup warrants airway evaluation first 4, 6
• Do not delay referral to pediatric pulmonology or otolaryngology for children with ≥3 episodes per year or severe episodes requiring hospitalization 1
• Do not miss feeding-associated symptoms (coughing with feeds, choking), as these indicate aspiration requiring urgent evaluation with modified barium swallow and possible bronchoscopy 4