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Croup

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Objectives

This guideline has been designed to assist in the diagnosis and management of children with croup. It includes a management algorithm and a list of potential differential diagnoses.

Scope

Children presenting with the signs of croup.

Audience

Healthcare professionals involved in acute paediatric medicine. 

November 2023: This guidance is currently under review as it has gone beyond the standard review date. It reflects best practice at the time of authorship / last review and remains safe for use. If there are any concerns regarding the content then please consult with senior clinical staff to confirm.

Croup is an acute respiratory illness causing inflammation and narrowing of the subglottic region of the larynx. It is most often caused by a viral infection.

Where appropriate (if severity allows) a minimally invasive HANDS OFF APPROACH allows best initial assessment– as children can look very different if allowed to settle for a few minutes

Key points:

  • If possible allow child to sit on carers lap – DO NOT FORCE TO LIE DOWN
  • Do not examine throat

  • If hypoxic try to give O2 by facemask

Signs

The following clinical signs (in varying combination) are found in croup:

  • Stridor
  • Barking cough
  • Hoarseness
  • Respiratory distress +/- Fever +/- Coryza
 
Assessment of SEVERITY is based on assessment of following parameters:
  • Respiratory rate
  • Heart rate
  • O2 saturations
  • Respiratory distress
  • Exhaustion
Algorithm For Management Of Child With Croup

Prednisolone
A single dose Prednisolone (1mg/kg) is not as effective as a single dose of dexamethasone for the treatment of croup. Therefore if using prednisolone as treatment for croup a second dose is recommended.
  • If prednisolone already given by GP and child has mild croup in ED may not need second dose, but if child has signs of moderate croup consider giving second dose prednisolone 1mg/kg
  • If for any reason dexamethasone not available – use prednisolone 1mg/kg once daily for 2 days
Differential diagnosis
It is essential to differentiate croup from other causes acute upper airway obstruction. The main differentials are:
  • Acute foreign body aspiration
  • Acute anaphylaxis
  • Bacterial upper airway infections e.g. epiglottitis, bacterial tracheitis.

Bacterial tracheitis is an infection of the tracheal mucosa (usually Staphylococcus aureus or Streptococci) which results in copious secretions and mucosal necrosis. The child usually appears very unwell (looks septic or ‘toxic’) with high fever, croupy cough and signs of progressive upper airway obstruction. The croupy cough and absence of drooling help to distinguish from epiglottitis. Treatment involves securing the airway (over 80% of children with this condition will need intubation) and IV antibiotics (cefotaxime and flucloxacillin)

Epiglottitis is caused by Haemophilus influenzae B infection, with resultant intense swelling of the epiglottis and surrounding tissues leading to airway obstruction. The onset is usually acute with a few hours of high fever, lethargy, soft inspiratory stridor and rapidly worsening respiratory distress. Cough is usually minimal or absent. The child appears toxic with a high fever and is often sitting immobile with their chin slightly lifted and mouth open drooling saliva. Attempts to lie the child down or painful procedures can precipitate complete upper airway obstruction and so should ideally only be done when the airway has been secured. Treatment involves urgent PICU review for airway assessment and management, bloods for culture and IV cefotaxime.

Table: Differentiation between croup, tracheitis and epiglottitis1
  Croup Tracheitis

Epiglottitis
Cause Viral

Staphyloccocus aureus
Streptococcus

 Haemophilus influenzae B

Age

 6m - 3yr Any age 2 - 6 yr

Onset

 Gradual Gradual Sudden

Pyrexia

 Mild >38oC >38oC

Abnormal sounds

 Barking cough, stridor Barking cough, stridor Muffled, gutteral cough

Swallowing

 Normal Difficult Very difficult with drooling

Posture

 Recumbent Sitting Tripod position

Facies

 Normal Anxious Anxious, distressed, toxaemic

 

Patient information leaflets

Croup patient information leaflets are available in English, Arabic, Romanian, Polish, Urdu and Mandarin using this link

References

Morton, N.S. Large airway obstruction in children: causes, assessment and management. Update Anaesth. 2004;18:1.

Editorial Information

Last reviewed: 24 February 2017

Next review: 31 October 2024

Author(s): Steve Foster

Approved By: Clinical Effectiveness

Reviewer Name(s): ED Department