Croup (from CKS)

Patient information leaflet (from UCLH)

Age groups

Croup affects about 3% of children per year, mostly between the ages of 6 months and 6 years
Peak incidence during the second year of life.

Aetiology

Croup (laryngotracheobronchitis) is caused by a virus (typically parainfluenza virus types 1 or 3).

Symptoms and Signs

1. Sudden onset of a seal-like barking cough
   stridor (predominantly inspiratory)
   hoarse voice
   respiratory distress due to upper-airway obstruction
   fever

2. PRODROMAL illness: 12–48 hour history of a non-specific cough, rhinorrhoea, and fever

3. Symptoms are usually worse at night

Differential diagnosis

• Epiglottitis:  suspect in a person with sudden onset high fever, dysphagia, drooling, anxiety, non-barking cough, and their preferred posture is sitting upright with head extended. This is rarely seen since widespread immunisation against Haemophilus influenzae B.

• Bacterial tracheitis: suspect in a person with fever, sudden onset stridor, and respiratory distress, following a viral-like respiratory illness from which the person appears to be recovering but then becomes acutely worse.

• Upper airway foreign body: suspect in a person with sudden onset dyspnoea and stridor, usually a clear history of foreign body inhalation or ingestion, no prodrome or symptoms of viral illness, and no fever (unless secondary infection)

• Retropharyngeal abscess/ Tonsillar abscess: suspect in a person with dysphagia, drooling, stridor (occasionally), dyspnoea, tachypnoea, neck stiffness, and unilateral cervical adenopathy. Onset is typically more gradual than with croup and is often accompanied by fever.

• Angioneurotic oedema: suspect in a person with acute swelling of the upper airway that may cause dyspnoea and stridor. Fever is uncommon. Swelling of face, tongue, or pharynx may be present. Can occur at any age.

• Allergic reaction: suspect in a person with rapid onset of dysphagia, stridor, and possible cutaneous manifestations (urticarial rash). Can occur at any age. Suspicion should be further raised if there is a personal or family history of prior episodes, or allergy. 

Assessment and classifying croup

MILD CROUP

seal-like barking cough
no stridor
no sternal/intercostal recession at rest.

MODERATE CROUP

seal-like barking cough
stridor at rest
sternal recession at rest
No agitation or lethargy

SEVERE CROUP

seal-like barking cough
stridor at rest
sternal/intercostal recession at rest
agitation or lethargy

IMPENDING RESPIRATORY FAILURE

upper airway obstruction
sternal/intercostal recession
asynchronous chest/abdomen movement
fatigue, pallor or cyanosis
decreased level of consciousness
agitation
respiratory exhaustion
**RR >70 breaths/minute

** The degree of chest wall recession may diminish with the onset of respiratory failure as the child tires.

MILD CROUP: oral dexamethasone, manage in community/home

single dose oral dexamethasone (0.15 mg per kg body weight)

MODERATE CROUP SEVERE CROUP or IMPENDING RESPIRATORY FAILURE:
Admit, dexamethasone +/-  nebulised epinephrine +/- oxygen therapy

oral dexamethasone (0.15 mg per kg body weight)
If too unwell, give 2 mg nebulised budesonide (single dose) or i.m. dexamethasome (0.6 mg/kg as a single dose)

SPECIAL GROUPS OF CHILDREN REQUIRING ADMISSION

Chronic lung disease
Congenital heart disease
Neuromuscular disorders
Immunodeficiency
Age <3 months
Inadequate fluid intake
Any factors that might affect a carer's ability to look after a child with croup
Longer distance to healthcare (in case of deterioration)

Prognosis

1. Self-limiting

2. Symptoms usually resolve within 48 hours

3. Consider use of paracetamol or ibuprofen to control fever and pain

Safety netting

1. Expected course of croup 48 hours.

2. Return to hospital if stridor can be heard continually, the in-drawing of ribs (intercostal recession) and/or the child is restless or agitated.

3. Call an ambulance if the child is very pale, blue, or grey , unusually sleepy, distressed breathing (chest recession, nasal flaring), agitation or restlessness, prefer to sit than lie down, and/or if they cannot talk, are drooling or trouble swallowing.

4. Advise the parents/carers to use either paracetamol or ibuprofen to treat a child who is distressed due to fever.
   [Antipyretic agents should not be used with the sole aim of reducing body temperature]

5. Advise the parents/ carers to check on the child regularly, including through the night.

6. Arrange follow-up, using clinical judgment to determine the appropriate interval.