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Croup is a common childhood respiratory illness with peak incidence in October and November. Inflammation of the subglottic structures results in obstruction of the upper airway, causing the characteristic barking cough, hoarseness, and inspiratory stridor. Fever may also be present. Patients with suspected croup should be assessed for more severe causes of upper airway obstruction, such as bacterial tracheitis, retropharyngeal abscess, peritonsillar abscess, foreign body obstruction, and epiglottitis. Radiography or laboratory testing is typically unnecessary for diagnosis but should be considered if the diagnosis is unclear. Corticosteroids are recommended as first-line treatment to reduce symptom burden and the need for advanced medical care. Dexamethasone is the most-studied corticosteroid, but prednisolone may also be used. A single oral dose of dexamethasone (0.6 mg/kg, maximum 12 mg) is standard. Moderate to severe croup should be treated with nebulized epinephrine and corticosteroids. Recurrent episodes of croup should prompt evaluation for an underlying anatomic abnormality or medical condition.

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

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.

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 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.

Most children who present with acute onset of barky cough, stridor, and chest-wall indrawing have croup. A careful history and physical examination is the best method to confirm the diagnosis and to rule out potentially serious alternative disorders such as bacterial tracheitis and other rare causes of upper-airway obstruction. Epinephrine delivered via a nebuliser is effective for temporary relief of symptoms of airway obstruction. Corticosteroids are the mainstay of treatment, and benefit is seen in children with all levels of severity of croup, including mild cases.

Background Human Parainfluenza Virus (hPIV) causes severe respiratory illness in infants and adults. Our study describes the association of hPIV1–4 with bronchiolitis, croup, and pneumonia using retrospective laboratory, administrative and public health data. Due to issues including the historic lack of hPIV4 in some commercial respiratory virus panels, the description of the impact of hPIV4 on croup, bronchiolitis, and pneumonia at population levels has often been limited. This study will use routine clinical laboratory data, and administrative data to provide a preliminary description of the impact of hPIV4 on these diseases in our population. Methods A three year cohort of patients positive for hPIV was linked with data from physician visits and hospital admissions to define cases and hospitalization status. International Classification of Disease (ICD-9) codes were used to determine if cases had croup, bronchiolitis, and pneumonia. We also looked at differences in hospitalization status, age and gender among hPIV1–4. All statistical analysis was done using SPSS (Version 19.0.0, IBM Corp© 2010) and Graphpad Prism V6 (GraphPad Software, Inc., 2012). Results Only hPIV1 and hPIV4 specimens had positivity rates greater than 5 % of all specimens sent for respiratory virus panel testing. hPIV1 exhibited a biennial pattern while the pattern for hPIV3 was less interpretable due to lower positivity rates. Circulation patterns for hPIV2 and hPIV4 were not assessed due to the low positivity rates of theses specimens. From 2010 to 2013, there were 2300 hPIV cases with hPIV3 (46 %) being the most common, followed by hPIV1 (27 %), hPIV4 (16 %) and hPIV2 (11 %). The median age was 2 years for all hPIV types. Males were slightly greater than females for hPIV1 and hPIV2, with an equal distribution for hPIV3 and slightly more females than males for hPIV4. hPIV1 and hPIV2 had the highest or proportion of croup while hPIV3 and hPIV4 had the highest proportion of pneumonia. Within hPIV4 cases, distributions of diseases were; pneumonia (21 %, 95 % CI 17.1–25.7), bronchiolitis (18 %, 95 % CI 14.3–22.5), croup (2 %, 95 % CI 0.8–3.9), mixed illness of any of pneumonia, bronchiolitis or croup (4 %, 95 % CI 2.5–7.0) or other respiratory diseases (54 %, 95 % CI 49.1–59.6). Conclusions We used laboratory and administrative data to undertake a descriptive analysis of the association of hPIV1–4 with croup, bronchiolitis and pneumonia. hPIV4 appears to be more associated more with bronchiolitis and pneumonia and less with croup in our population.

Croup is a common illness responsible for up to 15 percent of emergency department visits due to respiratory disease in children in the United States. Croup symptoms usually start like an upper respiratory tract infection, with low-grade fever and coryza followed by a barking cough and various degrees of respiratory distress. In most children, the symptoms subside quickly with resolution of the cough within two days. Croup is often caused by viruses, with para-influenza virus (types 1 to 3) as the most common. However, physicians should consider other diagnoses, including bacterial tracheitis, epiglottitis, foreign body aspiration, peritonsillar abscess, retropharyngeal abscess, and angioedema. Humidification therapy has not been proven beneficial. A single dose of dexamethasone (0.15 to 0.60 mg per kg usually given orally) is recommended in all patients with croup, including those with mild disease. Nebulized epinephrine is an accepted treatment in patients with moderate to severe croup. Most episodes of croup are mild, with only 1 to 8 percent of patients with croup requiring hospital admission and less than 3 percent of admitted patients requiring intubation.