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Background The Omicron variant of SARS-CoV-2 has been associated with unique clinical presentations in children, including croup-like symptoms such as barking cough, hoarseness, and respiratory distress. This study aimed to compare the clinical, laboratory, and treatment characteristics of hospitalized pediatric patients with croup who tested positive or negative for COVID-19 during the Omicron wave. Methods A retrospective, descriptive-analytical study was conducted on 111 pediatric patients hospitalized with croup at Bahrami Children’s Hospital and the Children’s Medical Center in Iran from January 21 to March 20, 2022. Patients were categorized into two groups: PCR-positive (Omicron group, n  = 30) and PCR-negative (non-Omicron group, n  = 81). Data on demographics, clinical severity, laboratory indices, treatments, and outcomes were extracted and analyzed using SPSS version 20. Results The mean age of the Omicron group was significantly younger (16.93 ± 24.80 months) compared to the non-Omicron group (32.58 ± 37.26 months; p  = 0.049). Symptom severity was higher in the Omicron group, with moderate to severe symptoms observed in 73.4% of patients, compared to 32.1% in the non-Omicron group ( p  = 0.001). The Omicron group had longer hospital stays (2.59 ± 3.93 vs. 2.11 ± 2.75 days; p  = 0.016) and required more nebulized epinephrine (2.47 ± 1.27 vs. 1.77 ± 1.003 days; p  = 0.003) and repeat corticosteroid doses (83.3% vs. 38.3%; p  = 0.0001). Laboratory findings showed no significant differences between the groups (all p  > 0.05). Conclusion Children with croup during the Omicron surge exhibited increased symptom severity, required more intensive treatment, and experienced longer hospital stays compared to those without COVID-19. These findings emphasize the need for heightened clinical awareness and tailored management strategies for Omicron-related croup in pediatric populations.

This placebo-controlled trial assessed the effectiveness of a single dose of dexamethasone in 720 children with mild croup who presented to the emergency department. Dexamethasone treatment was associated with more rapid resolution of symptoms, less loss of sleep, and a lower rate of return for medical care. Corticosteroid treatment can be of modest benefit for virtually all children with croup. Croup (acute laryngotracheobronchitis) is common, occurring yearly in 3 percent of children under six years of age. 1 Less than 5 percent of such children are hospitalized, and of these, 1 to 2 percent receive endotracheal intubation. 2 Corticosteroids are effective in moderate-to-severe croup, resulting in reductions in the frequency and duration of intubation 3 , 4 and hospitalization 5 – 7 and the frequency of administration of nebulized epinephrine, 5 , 7 a treatment reserved primarily for severe respiratory distress. At least 60 percent of children who present for emergency care have mild symptoms (defined as the presence of a barking cough, no audible stridor at rest, . . .

There is clear evidence that corticosteroids benefit children with symptoms of croup that range from mild to severe.32-34 In a meta-analysis of data from 10 clinical trials that included children with severe croup who required intensive care, corticosteroid treatment decreased endotracheal intubation by fivefold (odds ratio [OR] 0.21, 95% confidence interval [CI] 0.05 to 0.84).33A randomized clinical trial found that, in children admitted to hospital, corticosteroid treatment reduced length of hospital stay by one-third compared with placebo (duration of hospital stay: 12 h for dexamethasone and 13 h for budesonide v. 20 h for placebo, p < 0.03).35 In children who presented to emergency departments with moderate to severe croup included in a randomized clinical trial, cortico - steroid treatment reduced admission rates by half compared with placebo (35% v. 67%, p < 0.001).36 A randomized placebo-controlled trial included 720 children with mild croup seen in an emer- gency department and showed that corticosteroid treatment reduced return medical visits by half (7% v. 15%, p < 0.001), resulted in less stress and loss of sleep by parents, and reduced overall health care costs.37Whereas cortico ster oids appear to start reducing respiratory distress within an hour of oral administration,38,39 the drug effect continues to increase for at least 10 hours after administration.36 The reduction in the rate of use of health services, such as hospital admissions, is not significant until 3-6 hours after administration of corti co ster oids, which supports an observation period of that length before the decision is made whether to admit a child to hospital.36 The route of administration of corticosteroid (oral, nebulized or intramuscular injection) has received extensive study. Three randomized clinical trials comparing nebulized budesonide with either oral or intramuscular dexamethasone did not find a difference in duration of hospital stay (13 h for budesonide v. 12 h for intramuscular dexamethasone, nonsignificant),35 rate of admission to hospital (35% for budesonide v. 17% for intramuscular dexamethasone, p = 0.18)36 or clinical croup score at 4 hours (p = 0.70).44 Three randomized clinical trials have shown that intramuscular dexamethasone does not provide benefit over oral corticosteroid in either change in clinical croup score at 4 hours (p = 0.18),45 resolution of croup symptoms at 24 hours (2% for intramuscular v. 8% for oral administration, nonsignificant)46 or rate of return to medical care (32% for intramuscular v. 25% for oral administration, p = 0.198).47 The kinetics of oral dosing also show a rapid peak in serum levels occurring within 1 hour.48 However, nebulized administration could be considered in the rare case of a patient with sustained vomiting. Although comparatively few randomized trials have examined the benefit of nebulized epinephrine in children with croup,29,34,49,50 their results are sufficiently consistent and compelling to support its routine use to provide rapid, short-term relief of severe respiratory distress.51 These trials have shown onset of effect within 10 minutes and waning of effect between 1 and 2 hours.29,49,50 Whereas the few published trials have not shown any consistent benefit beyond short-term improvement in clinical score,51 data from an early historical cohort study showed a decreased number of intubations and deaths in children with croup following introduction of treatment with epinephrine.52 Evidence for the safety of using epinephrine in outpatients comes from 5 prospective cohort studies that included a total of 253 children who received epinephrine and dexamethasone.36,53-56 The studies found that 12 (5%) children returned for care within 48-72 hours after discharge, 6 (2%) were subsequently admitted to hospital and none had any other adverse event.36,53-56 A Cochrane review that included data from 8 randomized clinical trials found that treatment with nebulized epinephrine was associated with important clinical improvement in croup score 30 minutes following administration (standardized mean difference -1.56, 95% CI -2.23 to -0.89).51 In children admitted to hospital with croup, length of stay was shorter in the group that received nebulized epinephrine as compared with placebo (mean difference -32 h, 95% CI -59.1 to -4.9).51

Dear Editor, We have read this series pertaining to croup and COVID-19, written by Venn and colleagues [1], as described through the cases of three children with presentations of croup as a result of SARS-CoV-2 infections. The only positive viral infection in the patient was SARS-CoV-2 by PCR. Within our review of children presenting with the traditional croup-like symptoms (“barky cough, stridor, dyspnea [3], we have at least three more cases, in addition to the four mentioned above, that were negative for other viruses and only positive for COVID-19 by PCR.

Croup is a common respiratory illness affecting 3% of children six months to three years of age. It accounts for 7% of hospitalizations annually for fever and/or acute respiratory illness in children younger than five years. Croup is a manifestation of upper airway obstruction resulting from swelling of the larynx, trachea, and bronchi, leading to inspiratory stridor and a barking cough. Many patients experience low-grade fevers, but fever is not necessary for diagnosis. Less commonly, stridor can be associated with acute epiglottitis, bacterial tracheitis, and foreign body airway obstruction. Laboratory studies are seldom needed for diagnosis of croup. Viral cultures and rapid antigen testing have minimal impact on management and are not routinely recommended. Radiography and laryngoscopy should be reserved for patients in whom alternative diagnoses are suspected. Randomized controlled trials have demonstrated that a single dose of oral, intramuscular, or intravenous dexamethasone improves symptoms and reduces return visits and length of hospitalization in children with croup of any severity. In patients with moderate to severe croup, the addition of nebulized epinephrine improves symptoms and reduces length of hospitalization.

We describe three previously healthy children, admitted from our emergency department (ED) to our free-standing children's hospital, as the first documented cases of croup as a manifestation of SARS-CoV-2 infection. All three cases (ages 11 months, 2 years, and 9 years old) presented with non-specific upper-respiratory-tract symptoms that developed into a barky cough with associated stridor at rest and respiratory distress. All were diagnosed with SARS-CoV-2 by polymerase chain reaction testing from nasopharyngeal samples that were negative for all other pathogens including the most common etiologies for croup. Each received multiple (≥3) doses of nebulized racemic epinephrine with minimal to no improvement shortly after medication. All had a prolonged period of time from ED presentation until the resolution of their stridor at rest (13, 19, and 21 h). All received dexamethasone early in their ED treatment and all were admitted. All three received at least one additional dose of dexamethasone, an atypical treatment occurrence in our hospital, due to each patient's prolonged duration of symptoms. One child required heliox therapy and admission to intensive care. All patients were eventually discharged. Pathogen testing is usually not indicated in croup, but with “COVID-19 croup,” SARS-CoV-2 testing should be considered given the prognostic significance and prolonged quarantine implications. Our limited experience with this newly described COVID-19 croup condition suggests that cases can present with significant pathology and might not improve as rapidly as those with typical croup.

Croup is the leading infectious disease resulting in pediatric upper airway obstruction. Our purpose is to analyze diverse features of neck radiographs could be seen as an objective tool to predict outcomes in patients with croup. One hundred and ninety-two patients were prospectively recruited in pediatric emergency department with diagnosis of croup. The initial Westley score (WS), presence of steeple sign, extent of narrowing, and narrowing ratio on soft tissue neck radiographs were determined before and after treatments. The extent of frontal narrowing, extent of lateral narrowing, frontal ratio (FR), and lateral ratio (LR) were investigated to predict clinical outcomes in patients with croup. The extent of frontal/lateral narrowing and LR had significant correlation with outpatient status. Almost 71% of patients with FR values below 0.23 stayed in the hospital longer, whereas nearly 98% of patients with FR vales above 0.65 could be discharged. About 85% of patients with LR below 0.45 hospitalized longer. The LR and FR were significantly correlated with the severity and admission rate in croup. The LR > 0.6 and FR > 0.65 may indicate low risk in patients with croup, whereas the FR < 0.23 or LR < 0.45 may indicate the need of stay in hospital for further treatment and monitor.

Why did I do this work The National Review of Asthma Deaths (NRAD) found that for children that died from asthma, their parents/carers had extremely poor understanding of how to manage the condition and when to seek help. A Personalised Asthma Action Plan (PAAP) has been demonstrated to educate and empower children, young people and their families in effective self-management of their asthma. (BTS/SIGN).The capitalise the benefits of PAAP, we undertook a Quality Improvement Project (QIP) to maximise its deployment at the Children’s Unit at Royal Oldham Hospital.What did I do Retrospective record reviews were performed for all children admitted with the diagnoses of ‘asthma’ or ‘exacerbation of asthma’ to the Children’s Unit at the Royal Oldham Hospital in 2022, and subsequently in 2024.The reviews were carried out using the Electronic Patient Record systems: evolve and healthviews.Patients coded with viral induced wheeze, chest infection, croup, or were under the age of five at the time of presentation were excluded.For patients that met the inclusion criteria, evidence of PAAP deployment was searched for within their medical records.As an accessory element of this project, an anonymous questionnaire was circulated to assess the awareness of a PAAP and to identify barriers to its use.What did I find 0/16 patients were discharged with a PAAP in the 2022 cycle, and 3/23 in the 2024 cycle – a modest increase of 12%.In 2022, all surveyed staff members on the Children’s Unit were aware of the PAAP; and 94% in 2024.Despite this, only 45.5% of staff knew where to find it in 2022, compared to 69% in 2024, an increase of 23.5% due to the inclusion of PAAP in induction.81% of respondents to the anonymous staff survey selected time limitation as a barrier as a consequence of the fast-paced nature of the unit and the constant pressures to discharge patients to free up spaces – A conflict between quality and efficiency, sadly also commonly seen in most other hospitals.Respondents were asked to suggest interventions that would improve compliance. The highest-ranking suggestions were being shown PAAP’s at an induction to increase awareness and having an automatic option to add it on the computers when discharging with inhalers.What does it mean It is clear that the educational interventions in 2022 did not achieve the intended results, evidenced by the poor uptake in the 2024 cycle. Therefore, non-educational strategies must be implemented such as coupling the deployment of PAAP (e.g. as a pop-up) during online discharges to facilitate its use. We are confident that this proposed automated, coupled process will increase number of children discharged with Personalised Asthma Action Plans. A further cycle will confirm this.ReferencesNICE Guidance AsthmaBTS/SIGN – British guideline on the management of asthma

Acute upper airway obstruction has varied causes with distinct pathophysiological features. High-flow oxygen remains the basis for management, but improvements in equipment have increased the chances of success. Advances in anesthetic and surgical technologies are also improving success rates.