Croup - General Paediatrics

=Laryngotracheobronchitis. A viral illness of young children, caused mostly by parainfluenza but can also be due to RSV, influenza etc. Symptoms and signs predominately relate to upper airway narrowing. Characteristic barking (seal-like) cough, inspiratory stridor and difficulty breathing. Suprasternal recession is particularly evident. Other features of a viral illness eg rhinorrhoea, fever may also be present.

Respiratory symptoms are especially evident on waking, presumably due to accumulation of secretions, and are exacerbated by fear and upset. Can resolve rapidly.

Avoid upsetting the child, which may exacerbate symptoms. No attempt should be made to separate the child from its parents, or to examine the throat. Oxygen is rarely needed, so approaching the child with a face mask may do more harm than good. If hypoxic, the child is likely to be on the point of respiratory arrest or to have an alternative diagnosis. Filling a bathroom with steam is traditional but there is little evidence of benefit, it may upset the child and exposes the child to the risk of scalds.

Some children do appear to be susceptible to recurrent episodes, even in later childhood. There is some familial tendency.

Dexamethasone (0.6 mg/kg) and Prednisolone are useful for reducing clinical scores, preventing reattendance and improving sleep. Benefit is only seen after an hour or more. A second dose the following day is rarely needed. Dexamethasone may have a longer duration of action.N Engl J Med 2004;351:1306-13
Nebulized budesonide (2mg) also works but is expensive and probably offers no benefit in terms of onset of action.
Nebulized adrenaline 1mg in 5ml normal saline (regardless of age/size) is effective quickly but has a short duration of action (approx 30 minutes). It should be considered a stop gap while preparation for intubation is made.
Intubation is necessary for airway obstruction, but should be considered at a stage prior to complete obstruction, as the procedure is likely to be technically difficult. Appropriate staff eg consultant anaesthetist, ENT surgeon should be available, and transfer to a more appropriate location eg ENT theatre should be considered.

Differential Diagnosis:

Epiglottitis - toxic looking, little in the way of cough or airway noise
Tracheitis - usually older, more gradual onset, more toxic
Anaphylaxis with laryngeal oedema
Laryngomalacia and other chronic causes of upper airway obstruction, with or without added infection

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