Croup, medically known as laryngotracheobronchitis, is a common respiratory illness in young children characterized by a distinctive barking cough, stridor (a noisy, high-pitched sound with breathing), hoarseness, and varying degrees of breathing difficulty. This condition arises from inflammation and obstruction in the upper airway. Understanding the Diagnosis Croup process, symptoms, and management strategies is crucial for parents and caregivers to ensure timely and effective care for their child.
Croup primarily affects children between 6 months and 3 years old, with the peak incidence around 2 years of age. It is less common after 6 years old. Boys are slightly more affected than girls (ratio of 1.4:1), and there is no known ethnic predisposition. Typically caused by viral infections of the respiratory tract, croup is most frequently attributed to para-influenza viruses types 1 and 3. Outbreaks tend to occur biennially. While cases can appear throughout the year in regions like the UK, hospital admissions are highest in late autumn, from September to December.
Most cases of croup are mild and resolve within 48 hours, although some may persist for up to a week. Recognizing the signs and symptoms of croup is the first step towards effective diagnosis croup and management. Parents should be educated on home care practices, including maintaining hydration and using fever reducers, while being vigilant for signs that necessitate medical intervention.
Recognizing the Signs and Symptoms of Croup
The initial presentation of croup can resemble a common cold, featuring a mild fever and nasal discharge. Distinctive croup symptoms usually emerge a few days later and include:
- Barking cough: Often described as a “seal-like” cough, this is the hallmark symptom of croup.
- Hoarse voice: Inflammation of the larynx leads to a raspy or hoarse voice.
- Stridor: A high-pitched, whistling sound predominantly heard during inhalation, indicating airway narrowing.
- Difficulty breathing: Increased effort to breathe, which can range from mild to severe.
Symptom severity in diagnosis croup can vary widely, from mild discomfort to impending respiratory failure. Symptoms often worsen at night and with agitation. Although typically short-lived and self-limiting, croup can recur even after daytime improvement. Approximately 80% of children presenting with acute stridor and cough are diagnosed with croup.
While mild croup is often manageable at home, certain conditions warrant consideration for hospital admission. These include:
- Pre-existing chronic lung disease.
- Hemodynamically significant congenital heart disease.
- Neuromuscular disorders.
- Immunodeficiency.
- Age under three months.
- Dehydration, indicated by reduced fluid intake (50–75% of usual volume) or decreased urination (no wet diaper for 12 hours).
- Socioeconomic factors that may hinder adequate home care.
It is essential for parents and caregivers to be aware of “red flag” symptoms that require immediate emergency department referral, as outlined in Box 1.
Box 1: Red Flags for Emergency Department Referral in Diagnosis Croup
- Severe Breathing Difficulty: Struggling to breathe, grunting sounds, and stomach muscles pulling in under the ribcage (subcostal retractions).
- Color Changes: Blue, grey, or pale skin, lips, and tongue (cyanosis), indicating oxygen deprivation.
- Lethargy and Reduced Responsiveness: Unusual drowsiness, difficulty waking up, or decreased alertness.
- Quiet or Still Demeanor: Unusually quiet, less responsive, or inactive.
- Limpness or Floppiness: Loss of muscle tone, appearing limp or floppy.
- Agitation and Irritability: Restlessness, marked distress, and inconsolability.
- Swallowing Problems and Drooling: Difficulty swallowing saliva, excessive drooling, suggesting significant airway obstruction.
Source: https://www.nhs.uk/conditions/croup/
Image alt text: Illustration depicting a child experiencing croup symptoms, including a barking cough and breathing difficulties, highlighting key indicators for parents to recognize.
Risk Factors for Severe Croup
While most cases of croup resolve without significant intervention, certain risk factors increase the likelihood of severe disease. Recognizing these factors is vital for effective diagnosis croup and proactive management. Children with these risk factors may require closer monitoring and potentially more aggressive treatment. Box 2 lists the risk factors for severe croup.
Box 2: Risk Factors for Severe Croup in Diagnosis Croup
- Young Age: Infants, particularly those younger than six months, are at higher risk.
- Prematurity: Babies born prematurely may have underdeveloped airways, increasing vulnerability.
- History of Intubation: Children who have previously required intubation for respiratory issues are at higher risk for severe croup.
- Recurrent Croup: A history of previous croup episodes increases the risk of severe recurrence.
- Underlying Health Conditions:
- Neuromuscular disorders affecting breathing muscles.
- Chronic lung diseases such as asthma or bronchopulmonary dysplasia.
- Trisomy 21 (Down syndrome) with hypotonia (decreased muscle tone).
- Airway Abnormalities:
- Subglottic stenosis (narrowing of the airway below the vocal cords).
- Hemangioma (benign tumor of blood vessels) in the airway.
- Laryngomalacia or tracheomalacia (softening of the larynx or trachea).
The Diagnostic Process for Croup
Diagnosis croup is primarily clinical, relying on a detailed medical history and physical examination. A key aspect of diagnosis croup is differentiating it from other conditions that present with similar symptoms. Typically, physical examination reveals a low-grade fever and an absence of wheezing, which helps distinguish croup from asthma or bronchiolitis.
The Westley Croup Score is a standardized tool used to assess the severity of croup. This scoring system evaluates several factors, including the level of consciousness, presence of cyanosis, stridor, air entry, and retractions. Tables 1 and 2 detail the Westley Croup Score criteria and interpretation. Assessment of respiratory status, including respiratory rate, retractions (drawing in of the chest wall with breathing), stridor characteristics, heart rate, use of accessory muscles for breathing, and mental status, are crucial components of diagnosis croup. The presence of stridor and the degree of retractions are particularly reliable indicators of croup severity. Pulse oximetry can also be used to measure oxygen saturation levels, which may be reduced in more severe cases of croup. For most children with acute respiratory illness, maintaining oxygen saturation above 92% is desirable, with some clinicians aiming for 94–98%.
Patients exhibiting red-flag symptoms or those whose symptoms have a sudden onset and cause significant parental concern often present directly to the emergency department. Data from a large population-based study spanning from April 1999 to March 2015 indicated that out of 27,355 croup-related visits, 8.0% resulted in hospital admission, and 5.4% required a repeat visit within 7 days post-discharge.
Laboratory and imaging studies are generally not required for diagnosis croup in typical cases. However, they can be valuable in excluding other conditions in children with atypical or severe presentations. While a chest X-ray cannot definitively diagnose croup, it can help rule out other pulmonary pathologies when the diagnosis is uncertain. Differential diagnosis in diagnosis croup is guided by the patient’s history and physical examination findings. Although croup is the most common cause of abrupt onset stridor in children, a broad range of differential diagnoses must be considered. Table 3 lists potential differential diagnoses and their distinguishing clinical features.
Table 1: Westley Croup Score
| Clinical Feature | Score 0 | Score 1 | Score 2 | Score 3 | Score 4 | Score 5 |
|---|---|---|---|---|---|---|
| Level of Consciousness | Normal | Restless | Agitated | – | – | – |
| Cyanosis | None | With Agitation | At Rest | – | – | – |
| Stridor | None | Inspiratory | Inspiratory & Expiratory | At Rest | – | – |
| Air Entry | Normal | Mildly Decreased | Moderately Decreased | Severely Decreased | – | – |
| Retractions | None | Mild | Moderate | Severe | – | – |
Table 2: Interpretation of Westley Croup Score
| Score | Severity | Management |
|---|---|---|
| ≤ 2 | Mild Croup | Outpatient management, home care advice. |
| 3 – 7 | Moderate Croup | Hospital observation, consider corticosteroids. |
| ≥ 8 | Severe Croup | Hospital admission, corticosteroids, nebulized epinephrine, oxygen. |
Table 3: Differential Diagnosis of Croup
| Differential Diagnosis | Clinical Features |
|---|---|
| Epiglottitis | Sudden onset high fever, severe sore throat, drooling, toxic appearance, prefers sitting upright. |
| Bacterial Tracheitis | High fever, toxic appearance, thick purulent secretions, may follow viral croup. |
| Foreign Body Aspiration | Sudden onset choking or coughing, unilateral wheezing, absence of fever. |
| Spasmodic Croup | Recurrent episodes, sudden nighttime onset, absence of fever, mild symptoms. |
| Angioedema | Rapid onset swelling of face, lips, tongue, or throat, often with hives. |
| Retropharyngeal Abscess | Fever, neck stiffness, dysphagia (difficulty swallowing), muffled voice. |
| Peritonsillar Abscess | Severe sore throat, unilateral tonsillar swelling, trismus (lockjaw), hot potato voice. |
Image alt text: A doctor is shown gently examining a young child’s throat during a diagnosis croup assessment, illustrating the clinical examination process.
Management and Treatment of Croup
The management of croup is guided by the severity of the child’s condition, as indicated by the Westley Croup Score and clinical assessment. Mild croup can typically be managed at home with supportive care. Box 3 provides essential advice for pharmacists and pharmacy teams to share with parents and caregivers regarding home management of croup.
Box 3: Home Care Advice for Managing Croup
DO advise parents/caregivers to:
- Position the child upright: Sitting upright can ease breathing; avoid lying down flat.
- Comfort and Calm: Distress and crying can worsen symptoms; keep the child as calm as possible.
- Ensure Hydration: Provide plenty of fluids. For breastfed infants, continue breastfeeding frequently.
- Regular Monitoring: Check on the child frequently, including during the night, to monitor for symptom changes.
- Administer Antipyretics: If there are no allergies or contraindications, give paracetamol (acetaminophen) or ibuprofen to manage fever and discomfort.
DO NOT advise parents/caregivers to:
- Use Steam Inhalation: Steamy rooms or steam inhalation are not recommended. Evidence suggests potential risks, including fungal dispersion and scald injuries, without proven benefit for croup.
Dexamethasone in Croup Treatment
For all severities of croup (mild, moderate, or severe), a single dose of oral dexamethasone (0.15mg/kg) is the recommended first-line treatment. Dexamethasone, a corticosteroid, helps reduce airway inflammation. Improvement typically begins within 2–3 hours of administration, and the beneficial effects last for 24–48 hours. If dexamethasone is unavailable, oral prednisolone (1mg/kg) can be used as an alternative.
Usually, a single dose of dexamethasone is sufficient. However, a second dose may be considered if breathing difficulties and distress persist. Pharmacy teams should advise parents that if a second dose is needed, it should be given 12 hours after the first, if the child is awake and symptoms warrant it.
Local guidelines may vary slightly, but evidence indicates that dexamethasone doses of 0.15mg/kg and 0.6mg/kg are equally effective in reducing croup scores, hospital admission rates, and length of hospital stay.
A systematic review of 24 studies on glucocorticoids for croup treatment reported that serious adverse events, such as secondary bacterial infections (pneumonia, otitis media, bacterial tracheitis), were infrequent. Common side effects from short-term use are generally mild and may include behavioral changes, electrolyte imbalances, gastrointestinal discomfort, and nausea.
Contraindications for short-term glucocorticoid use are rare, especially when potentially life-saving. It is unlikely for children to experience significant side effects from one or two doses of dexamethasone for croup.
Dexamethasone is available in oral liquid and tablet forms. Tablets should be swallowed with liquid, and parents should be advised not to have children chew them due to taste. Tablets can be crushed and mixed with soft food if necessary to aid administration.
If oral steroids are not tolerated, inhaled budesonide (2mg nebulized as a single dose) or intramuscular dexamethasone (0.6mg/kg as a single dose) are alternative options.
Adrenaline (Epinephrine) for Moderate to Severe Croup
In moderate to severe croup cases, nebulized adrenaline (epinephrine) is used to provide rapid symptom relief. It has been shown to improve croup scores within 30 minutes, although the effects may diminish after about 2 hours. Reports indicate that adrenaline use in severe croup reduces the need for intubation or tracheotomy.
The recommended dose of nebulized adrenaline is 400 micrograms/kg (maximum dose 5mg), and it can be repeated after 30 minutes if needed. Side effects from a single dose are uncommon but could include arrhythmias, confusion, dizziness, dry mouth, hyperglycemia, hypokalemia, metabolic acidosis, and palpitations.
Despite initial steroid treatment, some children may not respond and can deteriorate. Nebulized adrenaline often provides significant short-term symptom improvement; however, a rebound effect with symptom recurrence is possible. Therefore, continuous monitoring in a medical setting is crucial for children treated with nebulized adrenaline to manage potential rebound symptoms effectively.
Supplementary oxygen and repeat adrenaline doses may be necessary. Respiratory failure is a rare complication, with intubation required in only 1–3% of croup cases. In children who do not respond to adrenaline, other causes of acute stridor should be considered.
Other Medication Considerations
Croup is primarily viral; therefore, antibiotics are not routinely indicated unless a primary or secondary bacterial infection is suspected. Pharmacy teams should advise parents against using cough medicines and decongestants, as these are ineffective for croup symptoms and may cause drowsiness, which can be dangerous in children with breathing difficulties.
Potential Complications of Croup
Complications from croup are infrequent but can include respiratory distress and otitis media (middle ear infection). Dehydration can occur if fluid intake is insufficient. Parents should be educated to watch for signs of complications, such as increased breathing difficulty, high fever, or altered alertness. Severe airway obstruction, although rare, is a serious potential complication requiring urgent medical intervention. Early recognition and treatment of complications are essential to prevent severe outcomes.
Hospital Discharge and Follow-Up
Children with mild croup can usually be discharged after a single dose of dexamethasone and appropriate parental education. Those with moderate croup should be observed for at least four hours post-dexamethasone and reassessed for symptom stability before discharge. Clear, written instructions on symptom monitoring and when to seek further medical care are crucial.
For moderate to severe cases, comprehensive parental education on home care, symptom monitoring, and hydration is necessary. Detailed written discharge instructions should be provided and documented. Follow-up care should be arranged on a case-by-case basis to monitor recovery and address any ongoing concerns.
Prevention Strategies for Croup
Preventing croup focuses on reducing the risk of upper respiratory infections. Parents should be advised to:
- Practice Good Hand Hygiene: Regular hand washing with soap and water is essential.
- Avoid Contact with Sick Individuals: Minimize exposure to people with respiratory infections.
- Vaccination: Ensure children are up-to-date on vaccinations, including the influenza vaccine, as viral infections are common triggers for croup.
- Avoid Tobacco Smoke: Exposure to tobacco smoke can exacerbate respiratory conditions and should be avoided.
When communicating with concerned parents, pharmacy teams should:
- Use Clear, Simple Language: Explain the condition and treatment plan using non-medical terms.
- Provide Reassurance: Emphasize the common and usually mild course of croup and the effectiveness of treatments like dexamethasone.
- Encourage Questions: Create an open environment for parents to express concerns and ask questions.
- Offer Practical Advice and Written Instructions: Provide concrete steps for home care and written materials to reinforce verbal advice.
- Demonstrate Empathy and Support: Acknowledge parental anxieties and offer empathetic support throughout the child’s illness.
