Croup » Clinical Guidelines

References:
  1. Bjornson, CL et al. .Croup. Lancet. 2008. 371(9609) 329-339.
  2. Bjornson, C., Russell, K.F., Vandermeer, B., Durec, T. Klassen, T.P., & Johnson, D.W. (2011). Nebulized epinephrine for croup in Children. Cochrane Database of Systemic Reviews, 2, 006619.
  3. Bjornson, C et al. A Randomized Trial of a Single Dose of Oral Dexamethasone for Mild Croup. NEJM. 2004. 351: 1306-13.
  4. Croup.(2008). CKS (Formerly PRODIGY)
  5. Diagnosis and management of croup.(2008). Toward Optimized Practice
  6. Johnson, et al. .Croup. Clinical Evidence. 2004; 12 401-426.
  7. Mazza, D., Wilkinson, F., Turner, T., Harris, C., & Health for Kids Guideline Development Group. (2008). Evidence based guideline for the management of croup. Australian Family Physician, 37(6 Spec No), 14-20.
  8. Russell KF, Liang Y, O.Gorman K, Johnson DW, Klassen TP. (2011) Glucocorticoids for croup. Cochrane Database of Systematic Reviews, 1, 001955.
Last updated: February 2014

Topic Owner: Julie Rivers, MD (Julie.rivers@seattlechildrens.org) and Mollie Grow MD MPH (mollie.grow@seattlechildrens.org)

OBJECTIVES:

  1. Provide criteria for accurate diagnosis
  2. Provide criteria for assessment of severity
  3. Provide criteria for transfer to emergency care
  4. Outline appropriate therapies
  5. Reduce unnecessary laboratory testing, radiography, and hospitalization
  6. Prevent return visits for croup and decrease overall costs

SUMMARY:

  1. Patient with mild to moderate croup symptoms should be treated with one dose of 0.6 mg/kg* of oral dexamethasone
  2. Patients with moderate or severe croup symptoms should all receive one 0.6 mg/kg dose of oral dexamethasone and be transferred to an emergency care setting for further management

*At provider discretion, may use 0.15-0.30 mg/kg dosing for mild cases

  1. Inclusion Criteria
    1. Previously healthy
    2. 6 months to 6 years of age
  2. Exclusion Criteria
    1. Symptoms suggestive of other diagnosis (expiratory wheeze, drooling or difficulty swallowing, prolonged or recurrent stridor, poor response to treatment)
    2. Known upper airway abnormality (laryngomalacia, tracheomalacia, history of vascular ring/sling or tracheoesophageal fistula)
    3. Hypotonia or neuromuscular disorder (trisomy 21)
  3. Assessment
    1. Definition: Acute viral infection that results in inflammation and swelling of the upper airway (also called laryngotracheobronchitis)
      1. Most common etiologies: Parainfluenza, RSV, influenza A and B, mycoplasma pneumoniae, other respiratory viruses
    2. Diagnosis: Croup is a clinical diagnosis made in the setting of acute onset of barky cough with or without inspiratory stridor, hoarse voice, and/or respiratory distress.
      1. May have a fever
      2. May be abrupt in onset or preceded by mild URI symptoms
      3. Symptoms are usually worse at night
    3. Diagnostic testing
      1. Perform pulse oximetry and obtain vital signs
      2. Do not routinely obtain a chest radiograph
      3. Do not routinely use viral testing
    4. Assess severity
      1. Mild to moderate croup
        1. Occasional barky cough
        2. No audible stridor at rest OR stridor at rest with no signs of distress
        3. No or mild suprasternal and/or chest wall retractions
        4. Child is happy and prepared to eat, drink and play
      2. Moderate to severe croup
        1. Stridor at rest AND one or more of the following:
          1. Prominent sternal wall retractions
          2. Tachypnea
          3. Agitation/restlessness/tired appearing
          4. Difficulty with talking or feeding
  4. Disposition
    1. Outpatient management recommended for:
      1. Patients with mild to moderate croup
    2. Indications for transfer to emergency department:
      1. Moderate to severe croup
      2. Hypoxemia (oxygen saturation <92%)
      3. Presence of co-morbid conditions
      4. Failure to respond to therapy
  5. Management
    1. Mild to moderate Croup
      1. Administration of single dose of oral dexamethasone (0.15-0.6 mg/kg, round dose to nearest 2 mg dosage, maximum dose of 16 mg)1,2
      2. No observation required prior to discharge
      3. There is no evidence for administering a second dose of oral dexamethasone
    2. Moderate to severe croup
      1. Arrange EMS transfer to local ED
      2. Make the child as comfortable as possible — often by sitting in the lap of parent
      3. Avoid agitation with unnecessary procedures
      4. Administer oral dexamethasone (0.6 mg/kg, round dose to nearest 2 mg dosage, maximum dose of 16 mg)
      5. Consider administration of nebulized racemic epinephrine 2.25% (0.5 ml in 2.5 ml saline) prior to transfer if available
  6. Disposition
    1. Discharge to home
      1. Patient must meet the following discharge criteria:
        1. Minimal stridor at rest (stridor with activity to be expected)
        2. Minimal retractions
        3. Able to talk or feed without difficulty
      2. If discharge criteria are met, provide verbal and written education materials for parents/caregivers
      3. Do not give additional steroids at discharge
      4. As always, consider family.s ability to return for appropriate follow up, or seek/access emergency care
      5. No specific follow-up is needed unless patient exhibits prolonged stridor (symptoms >7 days)
    2. Transfer to emergency department if:
      1. Patient meets initial criteria for indications for transfer to emergency department at any time
  7. Other Considerations
    1. If children are toxic appearing with high fever, and/or poor response to epinephrine, consider bacterial tracheitis
    2. If children have sudden onset of high fever, absence of barky cough, dysphagia, drooling, appear anxious and are sitting forward in the .sniffing position., consider epiglottitis and obtain a chest x-ray.

1 Some authors advocate for asking about immune deficiency or recent exposure to varicella prior to giving steroids

2 The majority of evidence exists for doses of 0.6 mg/kg. However, multiple smaller studies suggest that doses of 0.15 mg/kg or 0.3 mg/kg may be as effective as 0.6 mg/kg, but there is no clear consensus at this time. Providers should use their discretion when dosing dexamethasone (8).