Croup (laryngotracheitis and laryngotracheobronchitis)

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    Last updated: December 2023

     

    Common viral respiratory infection with peak incidence amongst children between 6 months and 3 years.

    Clinical features

    • Typical barking cough, hoarse voice or cry.
    • Inspiratory stridor (abnormal high pitched sound on inspiration):
      • Croup is considered mild if the stridor only occurs with agitation;
      • Croup is considered severe if there is stridor at rest, especially when it is accompanied by respiratory distress.
    • Wheezing may also be present if the bronchi are involved.

    Treatment

    • In the absence of inspiratory stridor or intercostal, subcostal or sternal retractions, treat symptomatically: ensure adequate hydration, seek medical attention if symptoms worsen (e.g. respiratory difficulty, noisy breathing, inability to tolerate oral fluids).

     

    • If stridor is only present with agitation (mild croup) [1] Citation 1. Pocket book of primary health care for children and adolescents: guidelines for health promotion, disease prevention and management from the newborn period to adolescence. Copenhagen: WHO Regional Office for Europe; 2022. Licence: CC BY-NCSA 3.0 IGO.
      https://www.who.int/europe/publications/i/item/9789289057622
      :
      • Assure adequate hydration.
      • Corticosteroids:
        • dexamethasone a Citation a. Administer orally if possible in order to avoid causing agitation in the child as this may worsen symptoms.  PO: 0.15 to 0.6 mg/kg (max. 16 mg) single dose
        • or, if not available, prednisolone PO: 1 mg/kg single dose
      • Keep the child under observation at least 30 minutes after oral corticosteroid. Consider hospitalisation or longer observation (> 4 hours) if the child is less than 6 months old, or is dehydrated, or lives far from health facility.

     

    • If danger signs are present (stridor at rest, respiratory distress, hypoxia) or the child is unable to drink, admit to hospital [1] Citation 1. Pocket book of primary health care for children and adolescents: guidelines for health promotion, disease prevention and management from the newborn period to adolescence. Copenhagen: WHO Regional Office for Europe; 2022. Licence: CC BY-NCSA 3.0 IGO.
      https://www.who.int/europe/publications/i/item/9789289057622
      :
      • Administer oxygen continuously if respiratory distress or SpO2 < 92%: maintain SpO2 between 94 and 98% (or if SpO2 cannot be determined, at least 5 litres/minute).
      • Insert a peripheral IV line and provide IV hydration.
      • Epinephrine (adrenaline) via nebulizer: 0.5 mg/kg (max. 5 mg) to be repeated every 20 minutes if danger signs persist (see table below).
        Monitor heart rate during nebulization (if heart rate greater than 200, stop the nebulization).

    Weight

    6 kg

    7 kg

    8 kg

    9 kg

    10-17 kg

    Dose in mg

    3 mg

    3.5 mg

    4 mg

    4.5 mg

    5 mg

    Dose in ml (1 mg/ml, 1 ml ampoule)

    3 ml

    3.5 ml

    4 ml

    4.5 ml

    5 ml

    NaCl 0.9% (a) Citation a. Add sufficient NaCl 0.9% to obtain a total volume of 4 to 4.5 ml in the nebulizing chamber.

    1 ml

    1 ml

     
    Epinephrine is intended exclusively for nebulized administration and should not be given IV or IM in croup.

     

    • Corticosteroids:
      • dexamethasone a Citation a. Administer orally if possible in order to avoid causing agitation in the child as this may worsen symptoms.   PO (or IM or IV if the child is vomiting): 0.6 mg/kg (max. 16 mg) single dose (see table below)
      • or, if not available, prednisolone PO: 1 mg/kg single dose

    Weight

    6-8 kg

    9-11 kg

    12-14 kg

    15-17 kg

    Dose in mg

    4 mg

    6 mg

    8 mg

    10 mg
    Dose in 2 mg tablet 2 tab 3 tab 4 tab 5 tab

    Dose in ml (4 mg/ml, 1 ml ampoule)

    1 ml

    1.5 ml

    2 ml

    2.5 ml

     

    • Suspect bacterial tracheitis in a critically ill appearing child b Citation b. Critically ill appearing child: weak grunting or crying, drowsiness, difficult to arouse, does not smile, disconjugate or anxious gaze, pallor or cyanosis, general hypotonia. with croup who does not improve with the above treatment.

     

     

    • If the patient has a complete airway obstruction, intubation if possible or emergency tracheotomy.

     

    Footnotes
    • (a) Administer orally if possible in order to avoid causing agitation in the child as this may worsen symptoms. 
    • (b)Critically ill appearing child: weak grunting or crying, drowsiness, difficult to arouse, does not smile, disconjugate or anxious gaze, pallor or cyanosis, general hypotonia.
    • (a)Add sufficient NaCl 0.9% to obtain a total volume of 4 to 4.5 ml in the nebulizing chamber.
    References
    • 1. Pocket book of primary health care for children and adolescents: guidelines for health promotion, disease prevention and management from the newborn period to adolescence. Copenhagen: WHO Regional Office for Europe; 2022. Licence: CC BY-NCSA 3.0 IGO.
      https://www.who.int/europe/publications/i/item/9789289057622