Croup is a clinical condition almost always caused by a viral infection of the upper respiratory tract that involves:
- inspiratory stridor (when air enters)
- barking cough
- hoarse voice
- variable respiratory difficulty (which is treated with oxygen in case of desaturation)
- presence/absence of fever: not always present, as often happens in acute viral bronchospasm but which, in both cases, should be treated with antipyretics ensuring good hydration.
What types of Croup exist?
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In addition to viral Croup, there is “spasmodic” Croup, not associated with other infectious symptoms (rhinitis, pharyngitis, diarrhea, etc.), characterized by sudden onset and cessation with well-being between attacks that can be more than one in the same night, in children with a family history of allergies.
Croup typically manifests in the early hours of the night, probably due to the physiological decrease in cortisol, our “endogenous cortisone” which, as we will see, is also the main therapy.
If the inflammation only affects the larynx, it is called laryngitis; if it also affects the trachea, it’s called laryngotracheitis.
The most commonly involved viruses are:
- parainfluenza viruses 1 and 3
- RSV (the bronchiolitis one!)
- influenza viruses A and B (those for which a vaccine exists!)
- adenovirus
- metapneumovirus
Croup is the leading cause of upper airway obstruction in children between 6 months and 3 years of age, especially around 2 years of age, becoming rare after 6 years.
What if it happens to an older child?
If an older child of more than 7-8 years has had “laryngeal,” “barking” cough for several days, without voice decrease, present during the day and absent at night, more during the week than on weekends, which prevents school attendance even for long periods, THINK ABOUT PSYCHOGENIC COUGH.
I have encountered several children with these characteristics, who had already taken a host of medications and undergone various specialist visits without any results, but they needed “only” a psychologist.
One of these had already over 30 days of absence by the end of December.
Characteristics of Croup
Croup is characterized by a fixed component (mucosal inflammation) and a dynamic component (which worsens with the child’s agitation/crying, who should always be calmed as much as possible, perhaps leaving them in the parents’ arms).
The therapy depends on the severity, and the severity is assessed with the Westley score (in the image below).
As you can see, the categories are:
Mild Croup (the majority of cases, manageable at home, Westley score 0-2)
For these cases: Oral Dexamethasone 0.15-0.6 mg/kg (max 10 mg) in a single dose (e.g., Soldedam and Decadron oral drops, Varcodes effervescent tablets)
Or:
Oral Prednisolone 1 mg/kg, repeating 1 dose the following evening (e.g., Sintredius)
Or:
Budesonide aerosol 2 mg (2 whole vials of 0.5 mg/mL, e.g., Bodix, Aircort, Pulmaxan).
N.B. 1 betamethasone (Bentelan), beloved by Italians, a panacea for all ills, is not reported as the first choice in the guidelines, nor are the effective dosages, despite being cortisone.
N.B. 2 beclomethasone (Clenil, Prontinal), beloved by Italians… see N.B. 1, which is the same!
Moderate Croup (Westley score 3-7) In these cases, the guidelines are:
Oral Dexamethasone 0.6 mg/kg (max 10 mg) in a single dose.
(or budesonide aerosol 2 mg but only if unable to administer dexamethasone).
Severe Croup (Westley score ≥8) For the most severe cases, the prophylaxis is as follows:
Adrenaline vials of 1 mg/ml: 0.25 mg/kg in aerosol (maximum 5 mg, i.e., 5 vials).
The effect is very rapid but the efficacy is not long-lasting, therefore administer:
Oral Dexamethasone 0.6 mg/kg (max 10 mg) in a single dose or Budesonide aerosol 2 mg.
Following in all three cases, aerosol with budesonide 1 mg (1 whole vial of 0.5 mg/mL) + 2 mL saline solution morning and evening for 2-3 days, until the cough becomes “soft.”
Is antibiotic therapy indicated?
No! The bacterial forms with which to make a differential diagnosis (acute epiglottitis from H. Influenzae, which only concerns the children of anti-vaxxers, and bacterial tracheitis) are extremely rare and do not represent classic forms of croup, which is viral just like acute bronchospasm.
P.S. the cold and humid air of winter helps, which is why children often arrive at the hospital in better conditions compared to those at home.
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SOURCES
1. Aregbesola A, Tam CM, Kothari A, Le M-L, Ragheb M, Klassen TP. Glucocorticoids for croup in children. Cochrane Database of Systematic Reviews 2023, Issue 1. Art. No.: CD001955. DOI: 10.1002/14651858.CD001955.pub5.
2. Elder AE, Rao A. Management and outcomes of patients presenting to the emergency department with croup: Can we identify which patients can safely be discharged from the emergency department? J Paediatr Child Health. 2019 Nov;55(11):1323-1328. doi: 10.1111/jpc.14412. Epub 2019 Feb 18. PMID: 30779245.
3. Cutrera R, Baraldi E, Indinnimeo L, Miraglia Del Giudice M, Piacentini G, Scaglione F, Ullmann N, Moschino L, Galdo F, Duse M. Management of acute respiratory diseases in the pediatric population: the role of oral corticosteroids. Ital J Pediatr. 2017 Mar 23;43(1):31. doi: 10.1186/s13052-017-0348-x. PMID: 28335827; PMCID: PMC5364577.
4. Lee JH, Jung JY, Lee HJ, Kim DK, Kwak YH, Chang I, Kwon H, Choi YJ, Park JW, Paek SH, Cho JH. Efficacy of low-dose nebulized epinephrine as treatment for croup: A randomized, placebo-controlled, double-blind trial. Am J Emerg Med. 2019 Dec;37(12):2171-2176. doi: 10.1016/j.ajem.2019.03.012. Epub 2019 Mar 8. PMID: 30878411.
5.https://secure.library.leicestershospitals.nhs.uk/PAGL/Shared%20Documents/Croup%20UHL%20Childrens%20UHL%20Childrens%20Guideline.pdf
6. Smith DK, McDermott AJ, Sullivan JF. Croup: Diagnosis and Management. Am Fam Physician. 2018 May 1;97(9):575-580. PMID: 29763253.