Croup (laryngotracheobronchitis) in children

J05.0-1

DESCRIPTION

Croup is a common cause of potentially life-threatening airway obstruction in childhood. It is characterised by inflammation of the larynx, trachea and bronchi. Most common causative pathogens are viruses, including measles.

A clinical diagnosis of viral croup can be made if a previously healthy child develops progressive inspiratory airway obstruction with stridor and a barking cough, 1–2 days after the onset of an upper respiratory tract infection. A mild fever may be present.

Suspect foreign body aspiration if there is a sudden onset of stridor in an otherwise healthy child.

Suspect epiglottitis if the following are present in addition to stridor:

  • very ill child
  • drooling saliva
  • high fever
  • unable to swallow
  • sitting upright with head held erect

Assessment of the severity of airway obstruction and management in croup

Grade 1
Inspiratory stridor only
  • Corticosteroids (intermediate-acting) e.g.:
    • Prednisone, oral, 1–2mg/kg, single dose.
      • Do not give if measles or herpes infection present.
    • Refer.

    LoEIII[24]
Grade 2
Inspiratory and expiratory stridor
  • Corticosteroids (intermediate-acting) e.g.:LoEIII[25]
    • Prednisone, oral, 1–2 mg/kg, immediately as a single dose.
    • Epinephrine, 1:1 000 diluted in sodium chloride 0.9%, nebulised, immediately
      • o Dilute 1 mL of 1:1 000 epinephrine with 1 mL sodium chloride 0.9%.
      • o Repeat every 15–30 minutes until expiratory stridor disappears
    • Refer.
Grade 3
Inspiratory and expiratory stridor with active expiration, using abdominal muscles
  • Treat as above
  • » If no improvement within one hour, refer urgently (intubate before referral if possible).
Grade 4
Cyanosis, apathy, marked retractions, impending apnoea
  • Intubate (if not possible give treatment as above).
  • Refer urgently .

LoEIII[24]

LoEIII[25]

GENERAL MEASURES

  • Keep child comfortable.
  • Continue oral fluids.
  • Encourage parent or caregiver to remain with the child.

MEDICINE TREATMENT

  • Paracetamol, oral, 10-15 mg/kg/dose 6 hourly when required. See paediatric dosing tool.

Children grade 2 or more stridor- while awaiting transfer:

  • Adrenaline (epinephrine), 1:1000, nebulised, immediately using a nebuliser.
    • If there is no improvement, repeat every 15 minutes, until the child is transferred.
    • Dilute 1 mL of 1:1000 epinephrine (adrenaline) with 1 mL sodium chloride 0.9%.
    • Nebulise the entire volume with oxygen at a flow rate of 6–8 L/minute.
  • Corticosteroids (intermediate-acting) e.g.: LoEIII[26]
  • Prednisone, oral, 1–2 mg/kg immediately as a single dose.

Weight
kg 		Dose
mg 		Tablet
5 mg 		Age
months/years
>11–14 kg 20 mg 4 tablets >2–3 years
>14–17.5 kg 30 mg 6 tablets >3–5 years

If epiglottitis suspected

  • Ceftriaxone, IM, 80 mg/kg/dose immediately as a single dose and refer. See paediatric dosing tool.
    • Do not inject more than 1 g at one injection site.

CAUTION: USE OF CEFTRIAXONE IN NEONATES AND CHILDREN

  • If SUSPECTING SERIOUS BACTERIAL INFECTION in neonate, give ceftriaxone, even if jaundiced.
  • Avoid giving calcium-containing IV fluids (e.g. Ringer Lactate) together with ceftriaxone:
    • If ≤ 28 days old, avoid calcium-containing IV fluids for 48 hours after ceftriaxone administered.
    • If > 28 days old, ceftriaxone and calcium-containing IV fluids may be given sequentially provided the giving set is flushed thoroughly with sodium chloride 0.9% before and after.
    • Preferably administer IV fluids without calcium contents.
  • Always include the dose and route of administration of ceftriaxone in the referral letter.

Management during transfer:

  • Give the child oxygen.
  • Continue nebulisations with epinephrine (adrenaline).
  • If grade 3, contact ambulance or nearest doctor.
  • If grade 4, intubate and transfer.

REFERRAL

Urgent

  • Children with:
    • chest indrawing
    • rapid breathing
    • altered consciousness
    • inability to drink or feed
  • For confirmation of diagnosis.
  • Suspected foreign body.
  • Suspected epiglottitis.

Non Urgent

  • All children grade1 or 2 stridor.