*—Large airway lesions include subglottic stenosis, laryngeal cleft, tracheomalacia, and laryngomalacia. The comparative effectiveness of prednisolone and dexamethasone for children with croup: a community-based randomized trial. Sign up for the free AFP email table of contents. Schuh S. Differentiate epiglottitis from viral croup. Anderson LJ. 10. Bjornson C, laryngotracheitis, which involves obstruction of the upper airway in If needed, treat for severe upper airway obstruction; Defer intravenous (IV) access 97/No. Viruses are detected in up to 80% of patients who have croup with identifiable pathogens.12 Parainfluenza virus (types 1 to 3) accounts for 75% of all cases, and human parainfluenza virus 1 is the most common type.9,13 Other viral etiologies include influenza A and B, adenovirus, respiratory syncytial virus, rhinovirus, and enterovirus. Otolaryngol Head Neck Surg. After completing this article, readers should be able to: Clarify the definition and terminology of viral croup. et al. Most children with mild croup symptoms can be successfully treated a… Cotton EK, Rales are generally not present in croup, so this finding should prompt further evaluation.12,13,16, More than 99% of children with abrupt stridor have croup, but the differential diagnosis is broad6 (Table 12,5,6,14,16–18). van Driel ML. Török TJ, Huang CT. If your organization uses OpenAthens, you can log in using your OpenAthens username and password. Lee DR, The danger of croup is that the airway can become so narrow that breathing becomes labored or impossible. aureus, …. Get Permissions, Access the latest issue of American Family Physician. Mild croup is characterized by the presence of stridor without intercostal retractions, whereas moderate‐to‐severe croup is accompanied by increased work of breathing. 2013;185(15):1317–1323. Klassen TP, 1. If you have a subscription you may use the login form below to view the article. Lee CH, Russell K, Pediatr Emerg Care 2005; 21:359. See flowchart; Supplemental oxygen is not usually required. Stephens D, 1997;176(6):1423–1427. 2011;83(9):1067–1073. the area of the larynx, infraglottic tissues, and trachea and is due to The Cochrane Library and safety of systemic corticosteroids for acute respiratory conditions in children: an overview of reviews. Even so, early identification and aggressive treatment are critical in this subgroup of very sick children in order to maintain this low mortality rate. 2019;144(3). In addition, references in these resources were searched. Am J Otolaryngol. 11 For severe croup, the APLS advocates racemic or L-epinephrine, followed by observation for 3 or 4 hours and hospital admission in the event of inadequate response or recurrence of severe distress. 1998;17(9):827–834. et al. Hartling L. 2016;30(1):70–75. Only 1 to 3% of children with croup are intubated, and even then the mortality rate of children intubated for croup is only 0.5% . Giannios C, Contact 9(May 1, 2018) Contact your librarian or administrator if you do not have a username and password. Moore M, • Ralston RL, et al. Laryngotracheitis, laryngotracheobronchitis, and laryngotracheobronchopneumonitis are included in the croup spectrum and affect 3% of children six months to three years of age.1,2 Each year in the United States, croup accounts for 7% of hospitalizations for fever and/or acute respiratory illness in children younger than five years.3,4. ; El-Hakim H. Moraa I, Regain Access - You can regain access to a recent Pay per Article purchase if your access period has not yet expired. Persad R, Won YK, Murray J. A Cochrane review showed improved symptom scores at six and 12 hours after treatment with a corticosteroid (dexamethasone, budesonide [Rhinocort], or methylprednisolone).22 Patients treated with corticosteroids have a lower rate of return visits, as well as decreased length of stay in the emergency department or hospital. Wald ER. Cochrane Database Syst Rev. Croup. laryngotracheobronchitis” frequently are used interchangeably in Taherahmadi H, Hoa M, Coates AL, Hall CB, Woods CR, Pediatric Emergency Research Canada Network. 4. Sturman N, Petrocheilou A, Rare causes of stridor (bacterial tracheitis & epiglottitis) must be considered and excluded. Describe the pathogenesis of viral croup. Clarify the definition and terminology of viral croup. Croup is a condition that causes a swelling of the voice box (larynx) and windpipe (trachea). 2013;(12):CD006822. Stay calm. Radiography and laryngoscopy should be reserved for patients in whom alternative diagnoses are suspected. Inpatient Treatment after Multi-Dose Racemic Epinephrine for Croup in the Emergency Department. Adapted with permission from Westley CR, Cotton EK, Brooks JG. 2013;52(11):1014–1021. Henderson FW. Moderate croup is usually managed with steroids alone, consider adrenaline if persistent or worsening symptoms; Severe croup requires nebulised adrenaline and steroids. Recurrent croup presentation, diagnosis, and management. This material may not otherwise be downloaded, copied, printed, stored, transmitted or reproduced in any medium, whether now known or later invented, except as authorized in writing by the AAFP. Croup typically resolves spontaneously within 48 hours to one week; however, the abrupt onset and harsh cough can be concerning.5,6. Taherahmadi H, Nebulized racemic epinephrine by IPPB for the treatment of croup: a double-blind study, Adapted with permission from Zoorob R, Sidani M, Murray J. Croup: an overview, . 13. Efficacy of nebulized L-epinephrine for treatment of croup: a randomized, double-blind study. Tanou K, Johnson DW. Australian Family Physician, 37(6 Spec No), 14-20. In patients with moderate to severe croup, the addition of nebulized epinephrine improves symptoms and reduces length of hospitalization. Coticchia JM. McGuire T, Copyright © 2018 by the American Academy of Family Physicians. 2008; 358(4):384–391. common and most typical form of the viral croup syndrome is acute et al. Johnson DW, In: Cherry JD, Demmler-Harrison GJ, Kaplan SL, et al., eds. Croup is a common respiratory illness affecting 3% of children six months to three years of age. The authors explain how to recognize viral croup, review the latest studies on when to use nebulized or systemic steroids, … Cherry JD. responsible for causing disease further down the respiratory tract, 1. Viral cultures and rapid antigen testing have minimal impact on management and are not routinely recommended. Pediatrics. Stroud RH , Friedman NR . It generally is accepted Many patients will also have dyspnea and fever,5,6 but the absence of fever should not reduce suspicion for croup. Kuruvilla G, Data Sources: A PubMed search was completed using the key terms croup and pediatric respiratory infection. Kwong K, 2012;147(2):209–214. Want to use this article elsewhere? et al. Croup is primarily a clinical diagnosis, with typical findings of abrupt onset of a barking cough, inspiratory stridor, and hoarseness (https://www.youtube.com/watch?v=RXJxtAHtkcs). Huang CT. / Journals Liang Y, Am J Dis Child. Budesonide offers no advantage when added to oral dexamethasone in the treatment of croup. Nebulized epinephrine for croup in children. Geelhoed GC. Croup: an 11-year study in a pediatric practice. Fernandes RM, From the American Academy of Pediatrics. Clarke MJ, Clinical practice. Viral croup: current diagnosis and treatment. Conlon B, Epinephrine decreases symptom scores in children with moderate or severe croup and should be given at the recommended dose of 0.05 mL per kg of racemic epinephrine 2.25% (maximum dose = 0.5 mL) or 0.5 mL per kg of L-epinephrine 1:1,000 via nebulizer (maximum dose = 5 mL).25,26. 2. Parainfluenza virus infection of young children: estimates of the population-based burden of hospitalization. acute angioneurotic edema). Although cyanosis is absent in most patients with croup, its presence suggests severe disease.12,13,16, The most common auscultatory finding is overt inspiratory stridor in the neck. 2014;9(3):733–747. Kaditis AG, Rowe BH, November 2014; 134 (5). Rudinsky SL, Sharieff GQ, Law W, Kanegaye JT. Recurrent croup presentation, diagnosis, and management. Tibballs J, Or Sign In to Email Alerts with your Email Address, To check if your institution is supported, please see, Review of Scabies Infestation and Selected Common Cutaneous Infections, Pediatric Ingestions: New High-Risk Household Hazards, Iron Deficiency: Implications Before Anemia, Follow American Academy of Pediatrics on Instagram, Visit American Academy of Pediatrics on Facebook, Follow American Academy of Pediatrics on Twitter, Follow American Academy of Pediatrics on Youtube. Am J Otolaryngol. Mayo Clin Proc. Clyde WA Jr, Figure 1 provides an outpatient management algorithm for children with croup.6,14,21–26 Minimizing agitation in a symptomatic child can help improve symptoms. Clinical Practice Guidelines DIAGNOSIS AND MANAGEMENT OF CROUP AUTHORS*: Michelle Clarke, MD FRCPC Division of Pediatric Emergency Medicine Department of Pediatrics, University of British Columbia BC Children’s Hospital 4480 Oak Street Vancouver, British Columbia Canada V6H 3V4 CLINICAL PRACTICE GUIDELINE TASK FORCE: CHAIRMAN: Paul Korn. the literature, they represent two different disease states. Reprints are not available from the authors. Faden H. Epinephrine should be administered to patients with moderate to severe croup. Cates CJ, Aring A. Lavine E, A Cochrane review showed that nebulized epinephrine reduces symptom scores at 30 minutes, but not at two and six hours; however, it is associated with reduced length of hospitalization.25 There was no initial difference between nebulized racemic epinephrine and L-epinephrine, although L-epinephrine was more effective at two hours because of its longer effects. Kahbazi M. 8. Bjornson CL, Fam Pract. Croup often starts, as many respiratory infections do, with a runny nose, fever, and a red, sore throat. 2014;49(5). J Pediatr. The effects of epinephrine wane after one to two hours, so patients should be monitored for at least two hours after administration before they are discharged.6,25 Although adverse effects of nebulized epinephrine are rare, patients receiving frequent treatments should be monitored for adverse cardiac effects. Russell K, Viral croup: current diagnosis and treatment. 25. Pediatr Pulmonol. Schuh S. It accounts for 7% of hospitalizations annually for fever and/or acute respiratory illness in children younger than five years. Published guidelines for the diagnosis and treatment of croup advise using steroids as the mainstay treatment for all children who present to emergency department (ED) with croup symptoms. Croup is a manifestation of upper airway obstruction resulting from swelling of the larynx, trachea, and bronchi, leading to inspiratory stridor and a barking cough. †Pediatric Infectious Diseases, Winthrop University Hospital, Mineola, NY. Immediate, unlimited access to all AFP content. Croup: Diagnosis and Management. laryngotracheitis, spasmodic croup, bacterial tracheitis, Croup: an overview. Pediatric Emergency Research Canada Network. O'Gorman K, Klassen TP. 1,2 It is a common cause of upper airway obstruction in young children. Hartling L. Print. Clinical Practice Guideline: The diagnosis, management and prevention of bronchiolitis. The Academy created the policy statem ent, "Classifying Recommendations for Clinical Practice Guidelines." An Update on Inflammatory Disorders of the Pediatric Airway: Epiglottitis, Croup, and Tracheitis. Korean J Pediatr. 15. Croup. Diagnosis of croup is based on clinical findings of barking cough, stridor, and hoarseness. Viral croup. Wald ER. Although the incidence of croup is highest between six months and three years of age, it can occur in children up to six years of age, or earlier than six months in atypical cases.5–7 Approximately 85% of cases are defined as mild, and less than 1% meet criteria for severe croup, which can be distinguished by signs of hypoxia.8,9 Less than 5% of all children with croup are hospitalized, and of those only 1% to 3% require intubation.10, In patients with recurrent croup (more than two episodes per year), clinically significant bronchoscopy findings are associated with risk factors such as prior intubation, prematurity, and age younger than three years. 23. Symptoms and signs differentiating croup and epiglottitis. Da Silva Z, JAMA. Diagnostic testing is typically not necessary. Parainfluenza virus infection of young children: estimates of the population-based burden of hospitalization. Amisha Malhotra, MD* 2. Russell KF, The search included meta-analyses, randomized controlled trials, clinical trials, and reviews. You will be redirected to aap.org to login or to create your account. • Petrocheilou A, et al. Cochrane Database Syst Rev. Clarke MJ, Feigin & Cherry's Textbook of Pediatric Infectious Diseases. Parainfluenza viruses are the most common cause of croup; however, other causes including epiglottitis and bacterial tracheitis should be considered in the differential diagnosis. agents alone, whereas both bacterial and viral agents may be Eghbali A, A single dose of orally administered dexamethasone (0.15–0.6 mg/kg) is the mainstay of treatment with addition of nebulized epinephrine only in cases of moderate‐to‐severe croup. 2018 May 1;97(9):575-580. J Infect Dis. 5 PCR testing has been shown to decrease the rate of radiographs ordered in the ED but has not been shown to decrease antibiotic use, length of stay in the ED, or blood or urine testing. DUSTIN K. SMITH, DO, is an assistant program director at the Jacksonville Family Medicine Residency Program, Naval Hospital Jacksonville (Fla.).... ANDREW J. MCDERMOTT, MD, is a faculty member at the Jacksonville Family Medicine Residency Program, Naval Hospital Jacksonville. Lavine E, Willis EB. Fundam Clin Pharmacol. The term “croup syndrome” refers to a group of diseases that Eghbali A, The views expressed in this article are those of the authors and do not necessarily reflect the official policy or position of the Department of the Navy, Department of Defense, or the U.S. government. Feigin & Cherry's Textbook of Pediatric Infectious Diseases. In mild croup, a child may present with only a croupy cough and may just require parental guidance and reassurance, given alertness, baseline minimal respiratory distress, proper oxygenation, and stable fluid status. 4. Data are limited on the benefit of heliox in the treatment of croup, and based on a Cochrane review of three conflicting trials, it is not recommended.29, Corticosteroids should be used in patients with croup of any severity. Weinberg GA, Klassen TP, The dramatic change in the epidemiology of pediatric epiglottitis. A randomized trial of a single dose of oral dexamethasone for mild croup. Denny FW, Nebulized epinephrine for croup in children. Garbutt JM, 18. Controlled delivery of high vs low humidity vs mist therapy for croup in emergency departments: a randomized controlled trial. Heliox for croup in children. Garbutt JM, 2. More seriously ill children require observation and treatment in the hospital. Croup in children. Sterkel R, Less than 6% of children presenting to ED with croup symptoms require hospitalization and when they are admitted, it is usually for a short stay . Clinical characteristics of children and adolescents with croup and epiglottitis who visited 146 emergency departments in Korea. Marx A, 2015;49(4):408-414. Kaditis AG, 1983;71(6):871–876. / afp 2011;83(9):1071, with additional information from references. All rights Reserved. McGuire T, Laboratory studies are seldom needed for diagnosis of croup. Evid Based Child Health. Croup (acute laryngotracheobronchitis) is a clinical syndrome characterised by barking cough, inspiratory stridor and hoarseness of voice with or without respiratory distress. Corticosteroids should be administered to patients with croup of any severity. This clinical content conforms to AAFP criteria for continuing medical education (CME). Atypical croup: association with airway lesions, atopy, and esophagitis. Klassen TP, Watters LK, Feldman ME, et al. 22. ; Kalampouka E, Humidified air inhalation for treating croup: a systematic review and meta-analysis. Rhonchi may be present but are not typical. Enlarge Steeple sign: not specific for croup. 24. Rosekrans JA. N Engl J Med. Russell KF, Treatment with dexamethasone results in faster resolution of symptoms and decreased return to medical care.21 Corticosteroids are thought to work by decreasing laryngeal mucosal edema through their anti-inflammatory effects. Rosekrans JA. Pediatr Emerg Care. If wheezing is present, it is typically mild; substantial wheezing should prompt evaluation for alternate diagnoses. Croup (Acute Laryngotracheobronchitis) Definition / Supporting Information Viral croup (acute laryngotracheobronchitis) is an age-specific viral syndrome characterised by acute laryngeal and subglottic swelling, resulting in: • Hoarseness • Cough • Respiratory distress (see Dyspnoea) • … Enter multiple addresses on separate lines or separate them with commas. Croup: an overview. Croup Care Guideline Recommendations/ Considerations Croup mainly occurs in children from 6 months - 3 years of age with a mean age of 18 months. A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. Zhao YD, Klassen TP, N Engl J Med. Evidence-Based Guidelines At least two comprehensive evidence-based guidelines covering the diagnosis, man-agement, and prevention of acute bronchiolitis have been published in the past 18 months. For information about the SORT evidence rating system, go to http://www.aafp.org/afpsort. 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. 2011;(1):CD001955. Marx A, ; Anderson LJ. Northern(California(Pediatric(Hospital(Medicine(Consortium.(Originated(1/2016.(Updated:(06/2016,(10/2017. 5. Henderson FW. Although radiographic imaging is not routinely indicated, croup is often associated with the steeple sign, which indicates glottic and subglottic narrowing (see http://www.aafp.org/afp/2004/0201/p535.html#afp20040201p535-f1). varies in anatomic involvement and etiologic agents and includes Viral croup: diagnosis and a treatment algorithm. Bronchoscopy findings in recurrent croup: a systematic review and meta-analysis. Nebulized racemic epinephrine by IPPB for the treatment of croup: a double-blind study. Rebound stridor in children with croup after nebulised adrenaline: does it really exist? The efficacy of nebulized budesonide in dexamethasone-treated outpatients with croup. However, this finding is neither specific nor sensitive for croup and may be present in patients with epiglottitis, bacterial tracheitis, neoplasm, or thermal injury.18 Computed tomography of the neck can be considered for patients with suspected abscess, tumor, or foreign body aspiration.5, Laryngoscopy should be reserved for atypical presentations or when alternate diagnoses are suspected.16 If epiglottitis is suspected, laryngoscopy should be performed with caution because of concern for rapid airway obstruction.6, Management of croup is based on the severity of illness. Viral croup, a common illness in children, manifests with noisy, labored breathing. Sidani M, Kalampouka E, Am Fam Physician. BMJ Clin Evid. Clinical Practice Guidelines are developed by multi-disciplinary subcommittees using an evidence-based approach, combining the best research available with expert consensus on best practice. We also searched the Cochrane database, Essential Evidence Plus, and the National Guideline Clearinghouse. Don't miss a single issue. Clinical Practice Guidelines. Malakasioti G, Croup in children. Leonard R. Krilov, MD† 1. Westley CR, Croup is a common respiratory illness of the larynx, trachea, and bronchi that leads to inspiratory stridor and a barking cough. The dramatic change in the epidemiology of pediatric epiglottitis. Copyright © 2020 American Academy of Family Physicians. Woods CR, an infectious agent. Kaditis AG. Clinicians should use age-appropriate rates; for patients six months to three years of age, a normal rate is 20 to 30 breaths per minute. • Richards AM. Consider evaluation and treatment for allergies Give Dexamethasone 2001 ; 22 ( 4 ): 268 – 275 Croup is a common respiratory illness affecting 3% of children six months to three years of age. Pediatrics. What is Croup? J Emerg Med. Giannios C, Address correspondence to Dustin K. Smith, DO, Naval Hospital Jacksonville, 2080 Child St., Jacksonville, FL 32214 (e-mail: email@example.com). Croup is a common respiratory illness in children. Persad R, Many patients experience low-grade fevers, but fever is not necessary for diagnosis. Pediatr Infect Dis J. 2004;69(3):535–540. Glucocorticoids for croup. Cotton EK, 101 defines United States Government work as a work prepared by a military service member or employee of the United States Government as part of that person's official duties. Information from references 2, 5, 6, 14, and 16 through 18. You may be able to gain access using your login credentials for your institution. Collier AM, Int J Pediatr Otorhinolaryngol. Croup is a co mmon illness in young children. Adapted with permission from Westley CR, Cotton EK, Brooks JG. A single dose of dexamethasone (0.15 to 0.60 mg per kg usually given orally) is recommended in all patients with croup, including those with mild disease. Pay Per Article - You may access this article (from the computer you are currently using) for 2 days for US$25.00. Zoorob R, 2009;154(5):694–699. Croup is a manifestation of upper airway obstruction resulting from swelling of the larynx, trachea, and bronchi, leading to inspiratory stridor and a barking cough. Patient information: See related handout on croup, written by the authors of this article. Little P. In patients with more than two croup episodes per year, clinically significant bronchoscopy findings are associated with risk factors such as prior intubation, age younger than three years, and prematurity. Compared with prednisolone, dexamethasone use in the emergency department or hospital may decrease rates of return visits or readmissions.22 However, a community-based randomized trial found no difference between single-dose dexamethasone and three daily doses of prednisolone for treatment of mild to moderate croup.24, Epinephrine is thought to improve symptoms in patients with croup through arteriole vasoconstriction in the upper airway mucosa, which eventually leads to decreased edema. Pcr in croup, the abrupt onset and harsh cough can be severe and rarely, life-threatening double-blind study interchangeably... 268 – 275 Pediatrics Disorders of the pediatric airway: epiglottitis, bacterial tracheitis, also known membranous. Practice Guideline: the diagnosis is primarily based on clinical findings of barking cough patients...: association with airway lesions, atopy, and the National Guideline Clearinghouse epinephrine should be reserved for patients whom! 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El-Hakim H. Atypical croup: a double-blind study Infectious Diseases, UMDNJ-Robert Wood Johnson School of Medicine, New,... ) and windpipe ( trachea ) symptoms ; severe croup except in cases for influenza testing for prophylaxis cohorting! You are a human visitor and to prevent automated spam submissions sakthivel M, Chryssanthopoulou D, P. Are used interchangeably in the literature, they represent two different disease States than! Ek, Brooks JG rapid antigen testing have minimal impact on management and are routinely. Related handout on croup, the abrupt onset and harsh cough can be severe rarely! Nasal flaring may indicate more severe cases and 16 through 18 diagnosis management... In the epidemiology of pediatric epiglottitis trip to the doctor ’ S office or emergency room tibballs J et... For clinical Practice guidelines are developed by multi-disciplinary subcommittees using an evidence-based approach, combining the best available... 21 through 26 Hospital Jacksonville Cotton EK, Brooks JG severe croup fever., keep your child comfortable with a runny nose, fever, and foreign body airway obstruction for... Supplemental oxygen is not available for any work of the population-based burden of hospitalization 6 Spec no ),.... — cuddle, read a book or play a quiet game hours one! 1,2 it is typically mild ; substantial wheezing should prompt evaluation for alternate diagnoses respiratory,. School of Medicine, New Brunswick, NJ Pediatrics about croup, the abrupt onset and harsh can! Fevers, but … 1, you can log in using your login credentials for your.... Runny nose, fever croup treatment guidelines aap and hoarseness, read a book or a... That may be able to gain access using your OpenAthens username and password than years! Are suspected management croup treatment guidelines aap prevention of bronchiolitis is often increased in patients with prolonged or recurrent croup and. Subscription you may be recurrent course of the population-based burden of hospitalization about the SORT evidence rating system, to! Represent two different disease States with significant bronchoscopy findings offers no advantage when to... Types, causes, symptoms, and laryngomalacia AM, Henderson FW a game..., Demmler-Harrison GJ, Kaplan SL, Sharieff GQ, Law W Kanegaye! 268 – 275 Pediatrics Permissions, access the latest issue of American Family.. 14, and treatments pediatric Practice laryngotracheobronchitis ) clinical Practice guidelines. PICU admission & Cherry 's Textbook of Infectious!, management and prevention of bronchiolitis infection is the most common cause of:! And winter fevers, but bacterial and Atypical agents also have been identified to: Clarify definition! Is more common in boys than in girls ( 1.5:1 ratio ) a quiet game and. For the treatment of croup: association with airway lesions include subglottic stenosis, laryngeal,... Tanou K, Kalampouka E, Malakasioti G, Persad R, El-Hakim H. Atypical:. Pubmed search was completed using the key terms croup and epiglottitis who visited 146 emergency departments Korea.