Croup

Author: Michelle Lin, MD
Updated: 8/20/2010

Croup

  • Laryngotracheobronchitis
  • Viral inflammatory condition of the subglottic airway
  • Typical age: 6 months-5 years
  • Cause: Parainfluenza in 80% cases
  • Presentation: hoarse voice, “barky” cough, low-grade fever, stridor, resp distress
  • Differential diagnosis: epiglottitis (which does not usually have URI sx and usually more toxic)
  • Video of child with croup

Westley croup scoring system

(Scoring systems not extensively evaluated)

Finding Points
STRIDOR
• None 0
• Only with agitation or excitement 1
• At rest with stethoscope 2
• At rest without stethoscope 3
RETRACTION
• None 0
• Mild 1
• Moderate 2
• Severe 3
AIR ENTRY
• Normal 0
• Decreased 1
• Severely decreased 2
CYANOSIS
• None 0
• With agitation 4
• At rest 5
LEVEL OF CONSCIOUSNESS
• Normal 0
• Altered mental status 5

Severity:

  • Mild (0-2)
  • Moderate (3-6)
  • Severe (>6)

Pearl: Check for cutaneous hemangiomas, because may be subglottic hemangioma (esp in age <6 mo)

CXR (AP view):

  • Not helpful to look for “steeple” sign.
  • Poor specificity and sensitivity

Treatment

  1. Keep child calm.
  2. Give supplemental oxygen
  3. Racemic epinephrine: Reduces airway edema. Use for moderate-severe respiratory distress. Observe 3-4 hours for rebound symptoms. Dose: 0.05 mL/kg diluted to 3 mL with NS - not to exceed 0.5 mL/dose (onset <30 minutes, duration 2 hours)
  4. Dexamethasone: Reduces severity and duration of croup, even in mild cases (Bjornson et al., NEJM, 2004). Dose 0.6 mg/kg po

NO longer part of treatment

  1. Cool mist: NO added benefit in moderate-severe croup (Scholnik, JAMA 2006)
  2. Humidified air: NO added benefit (Moore et al., Cochrane, 2006)

References

  • Sobol SE, Zapata S. Epiglottitis and Croup. Otolaryn Clin N Am. 2008, 41:551-66 [PubMed]
  • Scolnik D, Coates AL, Stephens D, Da Silva Z, Lavine E, Schuh S.Controlled delivery of high vs low humidity vs mist therapy for croup in emergency departments: a randomized controlled trial. JAMA. 2006 Mar 15;295(11):1274-80. [PubMed]
  • Moore M, Little P. Humidified air inhalation for treating croup. Cochrane Database Syst Rev. 2006 Jul 19;(3):CD002870. [PubMed]
  • Everard ML. Acute Bronchiolitis and Croup. Pediatr Clin N Am. 2009, 56:1 19-33 [PubMed]
  • Bjornson CL, Klassen TP, Williamson J, Brant R, Mitton C, Plint A, Bulloch B, Evered L, Johnson DW; Pediatric Emergency Research Canada Network.A randomized trial of a single dose of oral dexamethasone for mild croup.N Engl J Med. 2004 Sep 23;351(13):1306-13. [PubMed]