A 3-year-old male came to clinic with a history of a barky, seal-like cough the previous night.
He had had some rhinorrhea for 2 days but was afebrile. He had awoken with the cough and tachypnea.
His parents took him into the bathroom and used a humidifier and shower mist with good results.
He went back to sleep and was well in the morning, drinking and eating normally but with a coarse voice.
The pertinent physical exam showed normal vital signs and growth parameters including a respiratory rate of 21.
HEENT showed clear rhinorrhea, mild fluid in the left ear without other pathology, and a few pinpoint palatal vesicles.
Lungs were clear.
The diagnosis of croup was made. The physician discussed the possibility of using dexamethasone with the family. After talking about the potential dexamathason benefits and limitations of the available research, the family chose to not use it.
Followup showed that the illness resolved without problems.
Croup or acute tracheolaryngobronchitis is a common, self-limited disease caused by common respiratory pathogens especially Human Parainfluenza virus.
It can occur year round but often comes in waves particularly in fall, winter and early spring. Three percent of <6 year old children acquire it yearly with less than 5% of these requiring hospitlization. Of the hospitalized children, 1-2% require intubation.
Most children have mild symptoms (defined as a barky cough, no audible stridor at rest and no or mild retractions of the chest wall).
Often symptoms are worse at night and better during the day, and duration of symptoms generally last a few days.
Treatment for croup has included:
- Humdified air – many parents are instructed to create a steambath in a bathroom (with care so family is not burned by hot water), use a humidifier or take the child into the cool night air.
Clinical trials have not supported this use in some studies, but many clinicians have had experiences which do support its use.
- Racemic epinephrine – can be helpful in moderate or severe croup and its onset of improvement is often within 10-30 minutes, but efficacy usually decreases within a couple hours. Most children did not have worse symptoms after treatment than they had had before treatment.
- Heliox – data is equivocal for its use.
- Glucocorticoid medication – use of glucocorticord has been show to reduce hospital admission, decease stays in the emergency room and hospital and decrease other supplemental medication.
There is data that supports smaller doses of dexamethasone (0.15 mg/kg instead of standard 0.6 mg/kg) and that dexamethasone has a faster onset of action (30 minutes) than standardly believed (4+ hours).
Studies of croup often use the Westley Croup Score as a standard measurement of croup severity shown below.
At rest on auscultation
At rest without auscultation
|Chest Wall Retractions||None
Possible score 0-17 with:
mild croup < 4
moderate croup 4-6
severe croup > 6
Questions for Further Discussion
1. What are your indications for croup treatment with dexamethasone?
2. What causes respiratory distress?
- Disease: Croup | Throat Disorders
- Symptom/Presentation: Respiratory Distress
- Specialty: Allergy / Pulmonary Diseases | General Pediatrics
- Age: Preschooler
To Learn More
To view pediatric review articles on this topic from the past year check PubMed.
Evidence-based medicine information on this topic can be found at SearchingPediatrics.com, the National Guideline Clearinghouse and the Cochrane Database of Systematic Reviews.
Information prescriptions for patients can be found at MedlinePlus for this topic: Throat Disorders
To view current news articles on this topic check Google News.
To view images related to this topic check Google Images.
Westley CR, Cotton EK, Brooks JG. Nebulized racemic epinephrine by IPPB for the treatment of croup: a double-blind study. Am J Dis Child. 1978 May;132(5):484-7.
Geelhoed GC, Macdonald WB. Oral dexamethasone in the treatment of croup: 0.15 mg/kg versus 0.3 mg/kg versus 0.6 mg/kg. Pediatr Pulmonol. 1995 Dec;20(6):362-8.
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.
Vorwerk C, Coats T. Heliox for croup in children. Cochrane Database Syst Rev. 2010 Feb 17;(2):CD006822.
Bjornson C, Russell KF, Vandermeer B, Durec T, Klassen TP, Johnson DW. Nebulized epinephrine for croup in children. Cochrane Database Syst Rev. 2011 Feb 16;(2):CD006619.
Russell KF, Liang Y, O’Gorman K, Johnson DW, Klassen TP. Glucocorticoids for croup. Cochrane Database Syst Rev. 2011 Jan 19;(1):CD001955.
Moore M, Little P. Humidified air inhalation for treating croup. Cochrane Database Syst Rev. 2011 Jun 15;(6):CD002870. Author’s note: This has been withdrawn by the Cochrane Collaboration when reviewed on 10/6/12.
Dobrovoljac M, Geelhoed GC. How fast does oral dexamethasone work in mild to moderately severe croup? A randomized double-blinded clinical trial. Emerg Med Australas. 2012 Feb;24(1):79-85.
ACGME Competencies Highlighted by Case
1. When interacting with patients and their families, the health care professional communicates effectively and demonstrates caring and respectful behaviors.
2. Essential and accurate information about the patients’ is gathered.
3. Informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment is made.
4. Patient management plans are developed and carried out.
5. Patients and their families are counseled and educated.
8. Health care services aimed at preventing health problems or maintaining health are provided.
9. Patient-focused care is provided by working with health care professionals, including those from other disciplines.
10. An investigatory and analytic thinking approach to the clinical situation is demonstrated.
11. Basic and clinically supportive sciences appropriate to their discipline are known and applied.
12. Evidence from scientific studies related to the patients’ health problems is located, appraised and assimilated.
13. Information about other populations of patients, especially the larger population from which this patient is drawn, is obtained and used.
23. Differing types of medical practice and delivery systems including methods of controlling health care costs and allocating resources are known.
24. Cost-effective health care and resource allocation that does not compromise quality of care is practiced.
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa Children’s Hospital