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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

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, . . .

Croup treatment usually involves a single dose of systemic dexamethasone combined with nebulized epinephrine. However, the optimal dose of l-epinephrine remains unclear. We examined whether a low dose (0.1 mg/kg) was inferior to the conventional dose (0.5 mg/kg) of 1:1000 nebulized l-epinephrine in patients with moderate to severe croup. This randomized double-blind clinical non-inferiority trial was conducted in three pediatric emergency departments from May 2015 to October 2017. Children 6 months to 5 years old with moderate to severe croup (Westley scale scores 3–11) were eligible. Subjects were randomly assigned to the conventional dose (0.5 mg/kg: maximum 5 mg) or low dose (0.1 mg/kg; maximum 1 mg) group. All subjects received 0.6 mg/kg dexamethasone. Croup scores and other vital signs were measured before and at 30, 60, 90, and 120 min after nebulized l-epinephrine administration. The primary outcome was the change in croup score after 30 min. The final analysis included 84 patients. The groups did not differ significantly in terms of demographic parameters. At 30 min after treatment with nebulized l-epinephrine, the croup scores in both groups were significantly reduced from the baseline values (p < 0.05) and did not differ between the two groups (p = 0.42). Neither blood pressure nor heart rate differed between the two groups. Low-dose 1:1000 l-epinephrine was not inferior in croup score reduction to the conventional dose in patients with moderate to severe croup. Clinical trial No: NCT01664507, KCT0002318.

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.

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.

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.

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.

ObjectivesAlthough croup is a common respiratory illness, there is little published regarding symptom course. We aimed to assess symptom progression and caregiver burden, and whether age, sex or season and initial severity of disease are associated with symptom duration.Design, setting and participantsWe conducted a secondary analysis of two Canadian prospective cohorts of children 0–16 years old diagnosed with croup; one recruited from a paediatric emergency department (ED) (307 children) between November 1999 and March 2000, and the other from 26 general EDs (1214 children) between September 2002 and April 2006. Baseline data included age, sex, season, corticosteroid treatment and clinical severity score based on the presence or absence of a barky cough, stridor at rest or with agitation and chest wall indrawing (mild, moderate or severe). For both cohorts, the child’s primary caregiver was telephoned daily to collect symptom progression and psychosocial data (caregiver stress, lost sleep and work) until the child was symptom-free for over 24 hours.ResultsThe paediatric and general ED cohorts are reported separately; croup symptoms peaked at initial ED presentation for 96% and 77%, respectively. The longest-lived symptom was a barky cough, resolving by 34 and 47 hours for 50%, and 78 and 119 hours for 90% of children, respectively. Neither sex nor severity at presentation were significantly associated with symptom duration in either cohort. Season of illness was associated in both; age was associated in the general but not the paediatric ED cohort. The primary caregiver lost a mean (SD) of 4.1 (4.9) and 2.8 (4.7) hours of sleep during the illness.ConclusionsMost children with croup presented for care at the peak of symptom severity. Symptoms resolved for half of the children in 1.5–2 days and for 90% in 3–5 days after presentation. Caregivers experienced a significant loss of sleep.

Background: Croup remains a common respiratory problem presenting to emergency departments. A single oral treatment of oral dexamethasone results in improved outcome. Prednisolone has similar pharmacokinetic properties and has a significant advantage in that it is commercially available in liquid preparations. Objective: To ascertain whether a single oral dose of prednisolone was equivalent to a single oral dose of dexamethasone (matched for potency) in children with mild to moderate croup. Design: A double blind, randomised, controlled equivalence trial Setting: Tertiary paediatric emergency department. Patients: 133 children aged 3 to 142 months presenting with mild to moderate croup. Interventions: Children received either a single oral dose of dexamethasone 0.15 mg/kg or single oral dose of prednisolone 1 mg/kg. Outcome: The main outcome measure was unscheduled re-presentation to medical care as determined by telephone follow up at 7 to 10 days. Croup score, adrenaline (epinephrine) use, time spent in the emergency department, and duration of croup and viral symptoms were secondary outcome measures. Results: Children treated with prednisolone were more likely to re-present: 19 of 65 children (29%) reattended medical care compared with 5 of 68 (7%) from the dexamethasone group. The confidence intervals around this 22% difference in outcome were 8% to 35%, outside the 0% to 7.5% range of equivalence. There were no significant differences in other outcome measures. Conclusion: A single oral dose of prednisolone is less effective than a single oral dose of dexamethasone in reducing unscheduled re-presentation to medical care in children with mild to moderate croup.