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Children with Croup GP Summary


									                       Evidence-Based Guideline for Diagnosis & Management of

                             Children with Croup
                                 GP Summary
                                               How do I know it’s croup?
    A child is likely to have croup if they present with abrupt onset of barking cough, inspiratory stridor and hoarseness.
    The following clinical features should alert you to look for conditions other than croup in a child with croup-like
      •   Age less than 3 months                                    •   Drooling, difficulty swallowing, anxiety
      •   Expiratory wheeze or loss of voice                        •   Prolonged, or recurrent stridor
      •   Toxic appearance or high-grade fever                      •   Poor response to treatment
    Consider other diagnoses in children with recurrent croup.
    Radiography should not be used to diagnose croup or differentiate it from epiglottitis.
    X-rays may occasionally be warranted in patients with stridor where the diagnosis is uncertain.

                                               How do I assess severity?
               Mild                          Moderate                                Severe                      Life Threatening
•   Normal mental state           • Anxious, tired                       • Agitated, exhausted             • Confused, drowsy
•   No stridor or only when       • Stridor at rest
•   No or subtle accessory        • Minor accessory muscle use,          • Marked accessory muscle         • Maximal accessory muscle
    muscle use, tracheal tug or     tracheal tug or chest wall             use, tracheal tug or chest        use, tracheal tug or chest
    chest wall retraction           retraction                             wall retraction                   wall retraction or exhaustion
•   Normal heart rate             • Increased heart rate                 • Markedly increased heart
• Able to talk and/or feed        • Some limitation of ability to        • Increased respiratory rate      • Poor respiratory effort
                                    talk and/or feed                     • Too breathless to talk and/or   • Silent chest
                                                                         • Extreme pallor                  • Cyanosis
                                                                         • Low muscle tone
    Loudness of stridor is NOT a good indicator of the severity of croup
    Nasopharyngeal aspiration should NOT be undertaken in children with suspected croup.
    Distressing procedures should be kept to a minimum as agitation may worsen airway obstruction.

                                                   How do I manage it?
      Any child with croup who also has a pre-existing upper airway abnormality, or a significant relevant comorbidity or
      chronic illness should be sent by ambulance to an emergency department.
      Steroid use should be considered in mild croup and given in moderate–severe croup. Steroids should preferably be
      given orally, or intramuscularly if the child is vomiting.
      Use either: 0.60mg/kg dexamethasone or 1mg/kg oral prednisolone
?     Unlike asthma, there is insufficient evidence to determine whether multiple doses of corticosteroids are more
      effective than single doses

Mild croup                                     Moderate croup                                    Severe or life-threatening croup
      Consider steroids                             Give steroids                                   Call an ambulance
      Send home for observation if you              Children with moderate croup                    Give oxygen
      are confident the parent/carer                should be given corticosteroids
                                                                                                    Give adrenaline:
      can adequately manage the                     and observed over a 2-4 hour
      child’s illness                               period. These children can be                    o Nebulise four 1ml vials
                                                    managed in the surgery if                          (a total of 4mls) of 1:1000
                                                    facilities are available, otherwise                adrenaline solution
                                                    the child should be sent to                      o Do NOT dilute as this will
                                                    hospital                                           decrease the effectiveness
                                                                                                     o Drive nebulisation with oxygen
                                                                                                       where possible
                                                                                                    Give steroids
                      How do I advise parents of children with croup?
    Use of mist or humidified air is NOT an effective treatment for croup.
    Cold air has NOT been established as an effective treatment for croup.
    Children with croup should be allowed to adopt the position they find most comfortable.
    If at any time there is concern about a child’s ability to breathe, an ambulance should be
    called to take the child to hospital.
                   Parent information is available at

                                              Croup Cases
           Mild Croup                        Moderate Croup                          Severe Croup
Your receptionist slots in three-    Your receptionist calls you to see    You hear a frantic knock on your
year-old Suzy at 9.30am.             four-year-old Mei Ling who she        door…. “Please come quickly, this
                                     has placed in the treatment room      child looks very sick”.
Suzy has previously been well.
Mum says she had symptoms of a       as she looks unwell.                  An anxious looking mother is
cold for the last 48 hours and       As you walk in the door you           clutching a three-year-old boy
then last night at 2 am woke with    notice that the child looks anxious   who appears very pale, agitated
a barking cough and a hoarse         and is sitting quietly on her         and exhausted. He has marked
voice. From time to time through     father’s knee. She has inspiratory    chest wall retraction and tracheal
the night when she was running       stridor at rest and when you          tug and is too breathless to
around she had funny noisy           examine her chest you note that       respond to your questions. Mum
breathing but it settled by this     there is some tracheal tug and        says he developed noisy
morning. Mum thinks she might        chest wall retraction. Her pulse      breathing through the night and
have croup as Suzy's older           rate is 130. Dad says she was not     has deteriorated rapidly this
brother had it when he was her       able to eat or drink that morning.    morning.
age.                                 You diagnose moderate croup and       On examination he has an
On examination Suzy is happy,        administer 17mg of prednisolone       increased pulse and respiratory
alert and playing with the toys in   (her weight is 17kg).                 rate and poor air entry. You
your consulting room. She has a                                            diagnose severe croup and
                                     You explain the diagnosis to dad,     administer oxygen while asking
"seal" like cough from time to       provide him with information on
time, there is no temperature, no                                          your receptionist to call an
                                     the condition and then ring the       ambulance.
accessory muscle use, no             local emergency department. You
inspiratory stridor and her chest    explain to the father that the        You nebulise 4 x 1 ml vials of
is clear. Heart rate is normal and   child will require observation in     1:1000 adrenaline using the
she is able to talk, albeit with a   hospital to ensure she improves.      oxygen tank to drive it. Because
hoarse voice.                                                              the boy is unable to tolerate any
A provisional diagnosis of mild                                            oral intake, you draw up and
croup is made. You explain the                                             administer dexamethasone IM at
diagnosis to mum and provide her                                           a rate of 0.60mg/kg.
with information on the condition                                          By the time you do all that the
asking her to call or to return if                                         ambulance has arrived and
symptoms worsen.                                                           transports the child to hospital.

      Myths dispelled:                     We don’t know:                        Facts confirmed:
     The use of mist or               ? whether a second dose of                 Steroid use has markedly
     humidified air is NOT               steroid after 24 hours is               decreased the number of
     effective in the treatment          helpful when a child has                children needing hospital
     of croup                            continuing symptoms                     admission with croup

               Loudness of                                                       Either prednisolone
               stridor is NOT a                                                  or dexamethasone
               good indicator of                                                 can be used to
               the severity of                                                   treat croup

  Based on the Southern Health Evidence-Based Guideline for the Management of Croup in Children 2005
                                 available at

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