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Background and Objectives: Croup and bronchiolitis are common reasons for hospitalization in children, and the role of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection on utilization outcomes for these conditions is not well understood. To compare health care utilization including the rates of hospitalization, readmission, length of stay, and ICU admission for croup and bronchiolitis in children with and without evidence of concurrent SARS-CoV-2 infection over the pandemic period., Methods: This retrospective cohort study used inpatient and outpatient electronic health record data from PEDSnet institutions to examine health services use for children aged 30 days to 14 years with SARS-CoV-2 infection and diagnosed with croup or bronchiolitis. The time frame (March 2020-May 2022) was divided into predelta, delta, and omicron variant periods. Multivariable mixed effects logistic and log gamma regression models were used to calculate adjusted odds ratios for factors linked to utilization outcomes for children with versus without SARS-CoV-2 infections. Disease burden was described by variant time period., Results: Across all time periods, among subjects with croup and bronchiolitis, 9.65% of croup patients and 3.92% of bronchiolitis patients were SARS-CoV-2-positive. The omicron variant period had the highest number of SARS-CoV-2 cases for both croup and bronchiolitis. After controlling for patient-level variables and hospital variability, we found no statistically significant differences in utilization outcomes comparing children with and without SARS-CoV-2., Conclusions: Pediatric patients with croup and bronchiolitis and positive SARS-CoV-2 polymerase chain reaction testing did not exhibit a significant increase in hospital and ICU admissions, which may have implications for future staffing models and public health recommendations., Competing Interests: CONFLICT OF INTEREST DISCLOSURES: Dr Rao reports previous grant support from GSK and Biofire. Dr Bakel reports current grant support from Pfizer. Dr Jhaveri is a consultant for AstraZeneca, Seqirus, and Dynavax; receives an editorial stipend from Elsevier and the Pediatric Infectious Diseases Society; and receives royalties from Up To Date/Wolters Kluwer. The other authors have indicated they have no conflicts of interest relevant to this article to disclose., (Copyright © 2024 by the American Academy of Pediatrics.)

Objectives: Over-testing and over-treatment are common in children with croup at pediatric emergency departments (PED). The objective of the study was to improve care for children with croup., Methods: In this quality improvement (QI) initiative, all pediatric residents starting their rotation in the PED attended an informative presentation about croup and were provided reminders throughout their rotation. The primary outcome of this QI initiative was to reduce nebulized epinephrine (NE) use among children with mild croup by 50% over 7 months. The secondary outcome was to reduce X-rays by 50% over 7 months. Other outcomes included the administration of dexamethasone to all children with croup, reduction of antibiotics, laboratory tests, and revisits, and shortening the duration between physical examination to dexamethasone and NE treatments, and the length of stay (LOS) at the PED., Results: NE administration to patients with mild croup decreased from 80.2% to 36.3% ( p  < 0.001). The proportion of children with X-rays decreased from 37.4% to 17.1% ( p  < 0.001). There was a significant increase in dexamethasone administration, and significant decreases in laboratory blood tests, expanded viral PCR panel tests, and antibiotic prescription among all croup cases ( p  < 0.001). Revisit rates were not significantly different ( p  > 0.05). Time to dexamethasone and LOS shortened significantly ( p  < 0.001)., Conclusion: With this QI intervention, decreases in the rate of administration of NE to mild croup cases, antibiotic prescription, X-ray, laboratory blood and respiratory PCR panel tests in all croup cases were achieved without an increase in revisits. However, unnecessary NE, antibiotic, and X-ray rates are still high.

Objective: Since the global outbreak of the novel coronavirus disease 2019 (COVID-19), there have been increasing reports of children developing a croup-like cough associated with concurrent COVID-19 infection. Currently, there is not much information available regarding newborn infants and COVID-19 infection and the incidence of vertical transmission is thought to be rare. This novel case report depicts a term newborn infected at the time of birth with COVID-19 and includes details about the course of their complicated hospitalization., Study Design: A term infant, found to be infected at birth with COVID-19, developed respiratory distress resulting in transfer to our neonatal intensive care unit. Due to the increasing respiratory support requirements, endotracheal intubation was required on day of life (DOL) 7. Later, when the infant was extubated, on DOL 21, a croup-like cough developed., Results: Despite respiratory treatment with albuterol, budesonide, racemic epinephrine, lidocaine, dornase alfa, and a 10-day course of dexamethasone, the cough persisted. A prolonged hospitalization was required and eventually the infant was discharged home on 0.4 L/minute of oxygen via nasal cannula on DOL 95., Conclusion: As the COVID-19 virus mutates over time, there are some seemingly different presentations in both the pediatric and adult populations. The hypervigilance and sharing of new findings among providers are paramount in the treatment of infants with COVID-19 disease., Key Points: · Term infant with COVID-19 developed a croup-like cough.. · Usual respiratory treatment not effective with croup-like cough and COVID-19.. · COVID-19 present at birth later requiring intubation.., Competing Interests: None declared., (Thieme. All rights reserved.)

Objectives: To assess the impact of croup guidelines on healthcare utilization and association between guideline-recommended racemic epinephrine (RE) treatments and admission., Methods: Cross-sectional study of children ≥3 months to ≤8 years with croup diagnosis (International Classification of Diseases, 10th Revision) from 38 hospitals within the Pediatric Health Information System between January 1, 2019 and June 30, 2022. Guidelines were categorized by minimum number of RE treatments recommended before admission. Exclusion criteria included complex chronic or croup mimicking conditions, alternate respiratory diagnoses, and direct admissions or transfers. Primary outcomes were admission rates and standardized costs. Outcomes were compared by guideline availability and different admission thresholds. Mixed effects regression was adjusted for age, sex, race, payer, previous croup encounters, and year., Results: Twenty hospitals (52.6%) had guidelines. Fourteen recommended 2 RE treatments and 3 recommended 3 RE treatment before admission. Among 121 284 croup encounters, overall mean admission rate was 5.7% (range 0.6% to 18.5%). Hospitals with guidelines demonstrated lower unadjusted admission rate (4.6% vs 6.6%; mean difference -2.0, 95% confidence interval -2.3 to -1.7) and higher costs ($704 vs $651; mean difference 53, 95% confidence interval 43 to 63) compared with hospitals without guidelines. Hospitals with guidelines recommending 3 RE treatments demonstrated similar unadjusted mean admission rate (5.1%) and lower costs ($658 vs $713) compared with hospitals with guidelines recommending 2 RE treatments. After adjustment, all above-mentioned differences were not statistically significant., Conclusions: Many children's hospitals lack guidelines for croup. Admission rates and costs were not significantly different between hospitals with or without guidelines after adjusting for confounders., (Copyright © 2023 by the American Academy of Pediatrics.)

Background: Croup is one of the most common respiratory complaints in pediatric emergency departments (EDs), yet little is known about clinical practice guidelines (CPGs) for this condition., Objectives: To describe variation in CPGs across US children's hospitals., Methods: We describe the prevalence and features of CPGs among hospitals that submit data to the Pediatric Health Information System. Each hospital was contacted between January 10, 2022, and April 25, 2022, for their most recent croup CPG and any revisions. Characteristics reported were based on the most recent CPG revision. Characteristics included treatment recommendations, utilization measures, ED observation times, and admission criteria. Interrater reliability between reviewers was reported as percentage agreement., Results: Thirty-eight hospitals (79.2%) responded to our query, of which 20 (52.6%) had croup CPGs. Interrater reliability was moderate-high for categorizing the indication for racemic epinephrine (RE) (19 of 20; 95%), the minimum number of RE doses recommended before admission (15 of 20; 75%), and ED observation time (19 of 20; 95%), and was 100% for all other characteristics. Three CPGs (15.0%) recommended 1 RE dose, 14 (70.0%) recommended 2 RE doses, and 3 (15.0%) recommended 3 RE doses before hospital admission. Thirteen (65%) CPGs recommended RE for stridor at rest, whereas 7 (30%) recommended RE for any degree of stridor. Fourteen (70%) CPGs recommended an ED observation time <2 hours, 3 (15%) recommended 2 to 4 hours, and 2 (10%) recommended >4 hours. Few CPGs (15%) recommended use of standardized croup clinical scores., Conclusions: Substantial variation exists among croup CPGs. Our results may inform future efforts to standardize croup CPGs across centers., (Copyright © 2023 by the American Academy of Pediatrics.)

Background: Studies have found infrequent interventions after croup admission. Our objectives were to achieve 25% reduction in (1) admission rate and (2) neck radiograph utilization among patients presenting to the emergency department., Methods: At our tertiary children's hospital, we implemented clustered interventions including education, guideline, and orderset integration. We included patients 3 months to 8 years old with an emergency department, observation, or inpatient encounter for croup. We excluded patients with direct or ICU admissions, complex chronic conditions, or concurrent asthma, pneumonia, or bronchiolitis. We reviewed a random sample of 60% of encounters from baseline (October 1, 2017 to September 30, 2019) and implementation (October 1, 2019 to September 30, 2020) periods. We conducted a posthoc analysis from October 1, 2017 to December 1, 2021 to assess sustainment during coronavirus disease 2019. Interrupted time series analysis was used to evaluate changes in outcome, process, and balancing measures., Results: There were 2906 (2123 baseline and 783 implementation) encounters included. Extrapolating preintervention trend estimates, the baseline admission rate of 8.7% decreased to 5.5% postintervention (relative decrease 37% [95% confidence interval: 8 to 66]) and sustained over 26 months after implementation. Admission rate in patients receiving 2 or fewer racemic epinephrine was significantly lower in implementation (1.7%) compared with baseline (6.3%), relative decrease of 72% (95% confidence interval: 68 to 88). There were no significant changes in neck radiographs, length of stay, or revisits., Conclusions: Croup quality improvement interventions were associated with a significant decrease in hospital admissions with no increase in revisits., (Copyright © 2022 by the American Academy of Pediatrics.)

Croup refers to airway inflammation and edema leading to obstruction of the larynx, trachea, and bronchi. Croup is the most common cause of acute airway obstruction in young children. It is characterized by the onset of low-grade fever, barky cough, stridor, hoarseness, and respiratory distress. Croup is typically caused by a viral infection (viral croup) but can occur suddenly without a viral prodrome (spasmodic croup). Recurrent croup is defined as two or more episodes per year. Recurrent croup should be considered a symptom of an underlying structural or inflammatory airway abnormality and should prompt a work-up for the underlying cause., Competing Interests: Disclosure Nothing to disclose., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Aim: To evaluate the experience of NETS (The Newborn and paediatric Emergency Transport Service) New South Wales (NSW) with children referred with a provisional diagnosis of croup. To examine the adherence of referral hospitals to NSW Health policy guidelines and to establish criteria for the need to transfer and the level of escort required for a child with croup to a higher level of care., Methods: A retrospective audit of all children with a provisional diagnosis of croup referred to NETS over the epoch: 2005-2015. The NETS database was searched for keywords: croup and laryngotracheitis. Demographics, retrieval characteristics and management strategies were collected., Results: A total of 432 patients were identified. The number of children triaged to a medically led NETS team for transfer decreased (P < 0.001) whilst those transferred into more local regional or metropolitan hospitals (P < 0.001) increased. The number of adrenaline doses was not associated with intensive care admissions or the need for invasive ventilation., Conclusion: Medically led retrieval teams are not necessary for safe transfer of children with a provisional diagnosis of croup unless the airway is secured with an endotracheal tube. Transfer to more local hospitals for paediatric care should be considered and time allowed for medications to take effect prior to movement., (© 2021 Paediatrics and Child Health Division (The Royal Australasian College of Physicians).)

Background: Croup is an acute viral respiratory infection with upper airway mucosal inflammation that may cause respiratory distress. Most cases are mild. Moderate to severe croup may require treatment with corticosteroids (the benefits of which are often delayed) and nebulised epinephrine (adrenaline) (the benefits of which may be short-lived and which can cause dose-related adverse effects including tachycardia, arrhythmias, and hypertension). Rarely, croup results in respiratory failure necessitating emergency intubation and ventilation. A mixture of helium and oxygen (heliox) may prevent morbidity and mortality in ventilated neonates by reducing the viscosity of the inhaled air. It is currently used during emergency transport of children with severe croup. Anecdotal evidence suggests that it relieves respiratory distress. This review updates versions published in 2010, 2013, and 2018., Objectives: To examine the effect of heliox compared to oxygen or other active interventions, placebo, or no treatment on relieving signs and symptoms in children with croup as determined by a croup score and rates of admission and intubation., Search Methods: We searched CENTRAL, which includes the Cochrane Acute Respiratory Infections Group Specialised Register, MEDLINE, Embase, CINAHL, Web of Science, and LILACS, on 15 April 2021. We also searched the World Health Organization International Clinical Trials Registry Platform (apps.who.int/trialsearch/) and ClinicalTrials.gov (clinicaltrials.gov) on 15 April 2021. We contacted the British Oxygen Company, a leading supplier of heliox., Selection Criteria: Randomised controlled trials (RCTs) and quasi-RCTs comparing the effect of heliox in comparison with placebo, no treatment, or any active intervention(s) in children with croup., Data Collection and Analysis: We used standard methodological procedures expected by Cochrane. Data that could not be pooled for statistical analysis were reported descriptively., Main Results: We included 3 RCTs involving a total of 91 children aged between 6 months and 4 years. Study duration was from 7 to 16 months, and all studies were conducted in emergency departments. Two studies were conducted in the USA and one in Spain. Heliox was administered as a mixture of 70% heliox and 30% oxygen. Risk of bias was low in two studies and high in one study because of its open-label design. We did not identify any new trials for this 2021 update. One study of 15 children with mild croup compared heliox with 30% humidified oxygen administered for 20 minutes. There may be no difference in croup score changes between groups at 20 minutes (mean difference (MD) -0.83, 95% confidence interval (CI) -2.36 to 0.70) (Westley croup score, scale range 0 to 16). The mean croup score at 20 minutes postintervention may not differ between groups (MD -0.57, 95% CI -1.46 to 0.32). There may be no difference between groups in mean respiratory rate (MD 6.40, 95% CI -1.38 to 14.18) and mean heart rate (MD 14.50, 95% CI -8.49 to 37.49) at 20 minutes. The evidence for all outcomes in this comparison was of low certainty, downgraded for serious imprecision. All children were discharged, but information on hospitalisation, intubation, or re-presenting to emergency departments was not reported. In another study, 47 children with moderate croup received one dose of oral dexamethasone (0.3 mg/kg) with either heliox for 60 minutes or no treatment. Heliox may slightly improve Taussig croup scores (scale range 0 to 15) at 60 minutes postintervention (MD -1.10, 95% CI -1.96 to -0.24), but there may be no difference between groups at 120 minutes (MD -0.70, 95% CI -1.56 to 0.16). Children treated with heliox may have lower mean Taussig croup scores at 60 minutes (MD -1.11, 95% CI -2.05 to -0.17) but not at 120 minutes (MD -0.71, 95% CI -1.72 to 0.30). Children treated with heliox may have lower mean respiratory rates at 60 minutes (MD -4.94, 95% CI -9.66 to -0.22), but there may be no difference at 120 minutes (MD -3.17, 95% CI -7.83 to 1.49). There may be a difference in hospitalisation rates between groups (odds ratio 0.46, 95% CI 0.04 to 5.41). We assessed the evidence for all outcomes in this comparison as of low certainty, downgraded due to imprecision and high risk of bias related to an open-label design. Information on heart rate and intubation was not reported. In the third study, 29 children with moderate to severe croup all received continuous cool mist and intramuscular dexamethasone (0.6 mg/kg). They were then randomised to receive either heliox (given as a mixture of 70% helium and 30% oxygen) plus one to two doses of nebulised saline or 100% oxygen plus nebulised epinephrine (adrenaline), with gas therapy administered continuously for three hours. Heliox may slightly improve croup scores at 90 minutes postintervention, but may result in little or no difference overall using repeated-measures analysis. We assessed the evidence for all outcomes in this comparison as of low certainty, downgraded due to high risk of bias related to inadequate reporting. Information on hospitalisation or re-presenting to the emergency department was not reported. The included studies did not report on adverse events, intensive care admissions, or parental anxiety. We could not pool the available data because each comparison included data from only one study., Authors' Conclusions: Given the very limited available evidence, uncertainty remains regarding the effectiveness and safety of heliox. Heliox may not be more effective than 30% humidified oxygen for children with mild croup, but may be beneficial in the short term for children with moderate croup treated with dexamethasone. The effect of heliox may be similar to 100% oxygen given with one or two doses of adrenaline. Adverse events were not reported, and it is unclear if these were monitored in the included studies. Adequately powered RCTs comparing heliox with standard treatments are needed to further assess the role of heliox in the treatment of children with moderate to severe croup., (Copyright © 2021 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.)

We describe a case of croup in a 14-month-old boy caused by severe acute respiratory syndrome coronavirus 2, the virus that causes coronavirus disease 2019. The patient presented with classic signs and symptoms consistent with croup. Workup was remarkable for a positive point-of-care test for severe acute respiratory syndrome coronavirus 2. This case represents recognition of a new clinical entity caused by coronavirus disease 2019., Competing Interests: POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose., (Copyright © 2021 by the American Academy of Pediatrics.)

Objectives: We sought to determine predictors of hospitalization for children presenting with croup to emergency departments (EDs), as well as predictors of repeat ED presentation and of hospital readmissions within 18 months of index admission. We also aimed to develop a practical tool to predict hospitalization risk upon ED presentation., Methods: Multiple deterministically linked health administrative data sets from Ontario, Canada, were used to conduct this population-based cohort study between April 1, 2006 and March 31, 2017. Children born between April 1, 2006, and March 31, 2011, were eligible if they had 1 ED visit with a croup diagnosis. Multivariable logistic regression was used to determine factors associated with hospitalization, subsequent ED visits, and subsequent croup hospitalizations. A multivariable prediction tool and associated scoring system were created to predict hospitalization risk within 7 days of ED presentation., Results: Overall, 1811 (3.3%) of the 54 981 eligible children who presented to an Ontario ED were hospitalized. Significant hospitalization predictors included age, sex, Canadian Triage and Acuity Scale score, gestational age at birth, and newborn distress. Younger patients and boys were more likely to revisit the ED for croup. Our multivariable prediction tool could forecast hospitalization up to a 32% probability for a given patient., Conclusions: This study is the first population-based study in which predictors of hospitalization for croup based on demographic and historical factors are identified. Our prediction tool emphasized the importance of symptom severity on ED presentation but will require refinement before clinical implementation., Competing Interests: POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose., (Copyright © 2020 by the American Academy of Pediatrics.)

Background: For children who cannot be discharged from the emergency department, definitive care has become less frequent at most hospitals. It is uncertain whether this is true for common conditions that do not require specialty care. We sought to determine how the likelihood of definitive care has changed for 3 common pediatric conditions: asthma, croup, and gastroenteritis., Methods: We used the Nationwide Emergency Department Sample database to study children <18 years old presenting to emergency departments in the United States from 2008 to 2016 with a primary diagnosis of asthma, croup, or gastroenteritis, excluding critically ill patients. The primary outcome was referral rate: the number of patients transferred among all patients who could not be discharged. Analyses were stratified by quartile of annual pediatric volume. We used logistic regression to determine if changes over time in demographics or comorbidities could account for referral rate changes., Results: Referral rates increased for each condition in all volume quartiles. Referral rates were greatest in the lowest pediatric volume quartile. Referral rates in the lowest pediatric volume quartile increased for asthma (13.6% per year; 95% confidence interval [CI] 5.6%-22.2%), croup (14.8% per year; 95% CI 2.6%-28.3%), and gastroenteritis (16.4% per year; 95% CI 3.5%-31.0%). Changes over time in patient age, sex, comorbidities, weekend presentation, payer mix, urban-rural location of presentation, or area income did not account for these findings., Conclusions: Increasing referral rates over time suggest decreasing provision of definitive care and regionalization of inpatient care for 3 common, generally straightforward conditions., Competing Interests: POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose., (Copyright © 2020 by the American Academy of Pediatrics.)

Objective: To determine the extent to which care received by Australian children presenting with croup is in agreement with Clinical Practice Guidelines (CPGs)., Design: Retrospective population-based sample survey. Croup clinical indicators were derived from CPGs., Data Sources/study Setting: Medical records from three healthcare settings were sampled for selected visits in 2012 and 2013 in three Australian states., Data Collection: Data were collected by nine experienced paediatric nurses, trained to assess eligibility for indicator assessment and adherence to CPGs. Surveyors undertook criterion-based medical record reviews using an electronic data collection tool., Results: Documented guideline adherence was lower for general practitioners (65.9%; 95% CI: 60.8-70.6) than emergency departments (91.1%; 95% CI: 89.5-92.5) and inpatient admissions (91.3%; 95% CI: 88.1-93.9). Overall adherence was very low for a bundle of 10 indicators related to assessment (4.5%; 95% CI: 2.4-7.6) but higher for a bundle of four indicators relating to the avoidance of inappropriate therapy (83.1%; 95% CI: 59.5-96.0)., Conclusions: Most visits for croup were characterized by appropriate treatment in all healthcare settings. However, most children had limited documented clinical assessments, and some had unnecessary tests or inappropriate therapy, which has potential quality and cost implications. Universal CPG and clinical assessment tools may increase clinical consistency., (© The Author(s) 2019. Published by Oxford University Press in association with the International Society for Quality in Health Care. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Background: Croup is a common respiratory illness in children. It presents with a barky cough, stridor and hoarseness occurring secondary to inflammation of the subglottis and larynx. The clinical course of croup is well-described, however atypical presentations pose a diagnostic and management challenge., Objectives: This case report and systematic review aims to synthesize the published literature on the definition, diagnosis and treatment of atypical croup., Study Selection: Peer-reviewed journal publications in Ovid MEDLINE® and EMBASE from inception to January 1, 2019 in English, focusing on pediatric patients (<18 years of age) with diagnoses of atypical croup., Data Extraction: Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines., Results: Twelve studies involving 670 patients ranging from 6 months to 11 years of age presenting with atypical croup were selected. A variety of definitions of atypical croup were identified based on recurrence, duration of symptoms, severity, and etiology. Data on the incidence of atypical croup, the overall rates of intubation and tracheostomy, and patient characteristics leading to definitive airway management were not clearly characterized., Limitations: All studies were case series, case reports or retrospective chart reviews., Conclusions: Atypical croup is a poorly defined clinical entity that is used to describe recurrent, refractory, or croup-like illness that follows an uncharacteristic natural history. Our case presentation and accompanying literature review highlights the variable, but limited, information available on the diagnosis of atypical croup. Given the commonality of its use in clinical practice, we propose some guidelines around the use of the term 'atypical croup' as well as a management algorithm., (Crown Copyright © 2019. Published by Elsevier B.V. All rights reserved.)

Competing Interests: POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.

Objectives: There are no data to inform the ideal length of in-hospital observation after symptom improvement or to inform the ideal dexamethasone dose in critically ill children with croup. We describe a cohort of critically ill children with croup who rebound (have return of symptom(s) after meeting hospital discharge criteria) and examine the association between the cumulative dexamethasone dose before PICU discharge and both the odds and timing of rebound., Methods: In this single-center retrospective cohort study of subjects 6 months to 13 years of age admitted to the PICU with a primary diagnosis of croup, we employed multivariable logistic regression to evaluate the association between cumulative pre-PICU discharge dexamethasone dose and rebound. In the model, we controlled for subject age and sex, insurance, season, and history of prematurity, croup, or intubation. Kaplan-Meier curves were used to compare time to rebound between subjects receiving ≤2 standard (0.6 mg/kg) doses and those receiving >2 standard doses of dexamethasone before PICU discharge., Results: Data were analyzed over 69 months (January 2011-October 2016), and 275 unique subjects met inclusion criteria. The median cumulative dose of dexamethasone in the hospital was 1.57 mg/kg (interquartile range 0.98-2.63). Thirty-seven percent ( n = 102) of subjects developed rebound croup symptoms after meeting hospital discharge criteria. The median time to rebound was 13.1 hours (interquartile range 6.1-23.7). There was no association between cumulative pre-PICU discharge dexamethasone dose and the odds (odds ratio = 1.00; 95% confidence interval 0.83-1.19; P = .96) or timing of rebound., Conclusions: A clinically significant number of critically ill patients with croup rebounded. Total pre-PICU discharge dexamethasone dose did not predict either the odds or timing of rebound., Competing Interests: POTENTIAL CONFLICT OF INTEREST: Dr Dempsey serves on advisory boards for Merck and Pfizer; she does not receive any research funding from these companies; the other authors have indicated they have no potential conflicts of interest to disclose., (Copyright © 2019 by the American Academy of Pediatrics.)

An 88-year-old woman presented to our emergency room with complaints of fever, coryza, barking cough and generalised fatigue for 2 days. Physical examination showed stridor, tachypnoea with use of accessory muscles of respiration on admission. Laboratory tests were unremarkable except for monocytosis with a normal total white cell count. Rapid influenza diagnostic test was positive for influenza A. Chest X-ray showed subglottic narrowing of the trachea suggestive of steeple sign. A diagnosis of influenza A-induced croup was made. She was given humidified oxygen, nebulised racemic epinephrine, intravenous dexamethasone and oseltamivir. Stridor resolved within minutes of giving nebulised epinephrine. Work of breathing improved within 4-6 hours. She was discharged 2 days later on a tapering dose of steroids., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Ltd (unless otherwise stated in the text of the article) 2018. All rights reserved. No commercial use is permitted unless otherwise expressly granted.)

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.

Background: Westley croup score has been generally used to assess the severity of croup. This study aimed to identify the individual factors associated with Westley score (WS) and other clinical factors in predicting the outcomes in the pediatric emergency department (PED)., Population and Method: We prospectively recruited patients with croup from the PED. The individual factors of WS, fever, age, and the length of hospital stay were analyzed to predict clinical outcomes. We calculated all the areas under the receiver operating characteristic (ROC) curve to determine the cutoff values of initial WS discriminating the need for admission to the wards., Result: A total of 192 patients with croup were enrolled. Cyanosis and altered consciousness were not clinically significant even in patients with severe croup, whereas retraction and air entry were the major factors in WS for predicting clinical outcomes. The initial WS had a strong correlation with the length of hospital stay (r = 0.617, P < 0.001). ROC analysis showed that patients with an initial WS <2 (sensitivity, 5%; specificity, 100%; LR + , 1.05; LR - , 0; AUC, 0.87) were discharged home while the patients with an initial WS ≥5 (sensitivity, 99%; specificity, 57%; LR + , 41.0; LR - , 0.43) were more likely to require to stay in the PED. Patients with an WS ≥6 were more likely to be admitted to the wards (sensitivity, 97%; specificity, 47%; LR + , 416.35; LR - , 0.54; AUC, 0.90) CONCLUSION: Patients with an initial WS of 1-2 could be safely treated at home and those with initial WS >5 required hospitalization for further treatment., (© 2017 Wiley Periodicals, Inc.)

Educational outcomes, such as knowledge, confidence in performance, ability in nursing practice, and satisfaction with learning methods in caring for children with croup, were compared between groups of students that received education through simulation combined with pre-education, simulation only, and pre-education only. In this quasi-experimental design, the educational intervention for the experimental group was the pre-education modality. Data from a convenience sample of 127 senior nursing students were drawn from three nursing schools in South Korea. There were significant differences in the mean scores of knowledge, confidence in performance, satisfaction with the learning method, and ability in nursing practice between the three groups. Pre-education with simulation significantly enhanced students' knowledge, confidence in performance, ability in nursing practice, and satisfaction with learning methods compared with pre-education or simulation alone. Simulation strategies should focus more on enhancing nursing students' learning outcomes., (© 2017 John Wiley & Sons Australia, Ltd.)

Background and Objectives: Croup is a clinical diagnosis, and the available evidence suggests that, except in rare cases, ancillary testing, such as radiologic imaging, is not helpful. Given the paucity of inpatient-specific evidence for croup care, we hypothesized that there would be marked variability in the use of not routinely indicated resources (NRIRs). Our primary study objective was to describe the variation and predictors of variation in the use of NRIRs., Methods: This was a retrospective cohort study that used the Pediatric Health Information System database of generally healthy inpatients with croup aged 6 months to 15 years who were admitted between January 1, 2012 and September 30, 2014. We measured variability in the use of NRIRs: chest and lateral neck radiographs, viral testing, parenteral steroids, and antibiotics. Risk-adjusted analysis was used to compare resource utilization adjusted for hospital-specific effects and average case mix., Results: The cohort included 26 hospitals and 6236 patients with a median age of 18 months. Nine percent of patients required intensive care services, and 3% had a 30-day readmission for croup. We found marked variability in adjusted and unadjusted utilization across hospitals for all resources. In the risk-adjusted analysis, hospital-specific effects rather than patient characteristics were the main predictor of variability in the use of NRIRs., Conclusions: We observed an up to fivefold difference in NRIR utilization attributable to hospital-level practice variability in inpatient croup care. This study highlights a need for inpatient-specific evidence and quality-improvement interventions to reduce unnecessary utilization and to improve patient outcomes., Competing Interests: POTENTIAL CONFLICT OF INTEREST: Dr Dempsey serves on advisory boards for Merck and Pfizer. She does not receive any research funding from these companies. The other authors have indicated they have no potential conflicts of interest to disclose., (Copyright © 2017 by the American Academy of Pediatrics.)

Objective: The objective was to derive a simple clinical scoring instrument for assessing children with croup by telephone for use in clinical research studies., Methods: We reviewed published literature on croup scores, surveyed experienced pediatric emergency nurses and physicians, and conducted a prospective cohort study. Score items were derived from published literature and surveys of experienced clinicians. We enrolled children with croup attending an urban pediatric emergency department. Families of children enrolled were contacted daily by telephone and asked standardized questions about their child's clinical symptoms and family functioning. Data from this survey were used to derive the clinical score., Results: We identified 11 unique croup scores from the literature and interviewed 6 experienced clinicians. We enrolled 330 children and achieved complete follow-up for 301. Of the various groupings of items and duration of assessment, the 2-item score (barky cough and stridor) was the simplest and most reliable. Three days of follow-up yielded optimal correlations., Conclusions: We derived a 2-item Telephone Out Patient score assessed daily for 3 days after an emergency department visit. Validation of this score in a future, independent prospective cohort is needed.

Croup remains the commonest reason for acute upper airway obstruction in children, yet there are scarce contemporary data of airway management in those requiring intubation. We performed a retrospective analysis of the intensive care management of children intubated for croup in two quaternary Paediatric Intensive Care Units: Royal Children's Hospital Melbourne, Australia and Alberta Children's Hospital Calgary, Canada. Patients intubated for less than three days were compared with those intubated for greater than three days. Patients less than 10 kg body weight were compared to those greater than 10 kg. Demographic, clinical and microbiological data were recorded. Seventy-seven cases of croup requiring intubation were identified. The median duration of intubation was 60 hours. Parainfluenza was the most common viral aetiology, detected in 30% of cases. Antibiotics were prescribed in 51% of patients. Corticosteroids were prescribed pre intubation in two-thirds of patients and all post intubation, with the median dose being prednisolone 3 mg/kg/day. Primary extubation failure occurred in 6.5% of patients. Neither the duration of intubation nor patient size were associated with extubation failure. An air leak test was performed in 69% of patients and poorly predicted extubation success. One non-urgent tracheostomy was performed and there was one death from hypoxic ischaemic encephalopathy. Endotracheal tube leak is poorly recorded and may not predict successful extubation.

Acute respiratory distress is one of the most common reason for emergency visits in children under 5 y of age. An accurate understanding of the epidemiology of these diseases, identification of risk factors and etiology is critical for successful treatment and prevention of related mortality. The cause of acute respiratory distress varies in etiology, and hence is amenable to different treatment modalities. Depending on the predominant symptoms and signs, a child presenting to the clinician can be divided into six groups, viz., stridor; cough, fever and difficulty in breathing or fast breathing; wheezing; mediastinal shift with severe respiratory distress; slow or irregular breathing in absence of any pulmonary sign; and respiratory distress with cardiac findings. A detailed history followed by a thorough clinical examination and laboratory evaluation assisted by imaging modalities if indicated, helps to establish the exact cause of respiratory distress in the child. Early recognition and prompt institution of appropriate management or referral can significantly improve the outcome of this illness. This article offers clinicians a brief update on the general management guidelines of respiratory distress in pediatric patients. Specific treatment depends on the exact cause, however croup and acute severe asthma have been discussed in this article.

Objective: To evaluate the results of our multidisciplinary approach to recurrent croup and chronic cough., Methods: Retrospective chart review of all patients with recurrent croup and chronic cough managed at a tertiary care children's hospital by our Comprehensive Airway, Respiratory, and Esophageal (CARE) Team. Charts were reviewed for all patients who carried a diagnosis of recurrent croup or chronic cough. Patients were excluded if they did not receive a full workup, including micro-direct laryngoscopy, flexible and/or rigid bronchoscopy, bronchioalveolar lavage (BAL), and upper endoscopy with biopsies. We reviewed the records for the presence of gastrointestinal complaints, abdominal pain and failure to thrive (FTT) and compared the children with documented esophagitis to the remaining children., Results: Forty patients met inclusion criteria. 53% had airway abnormalities; the most common was tracheomalacia, followed by enlarged adenoids. 38% had esophagitis (group 1) while 62% had normal esophageal biopsies (group 2). Among the children in group 1, 27% met criteria for eosinophilic esophagitis (>15 eosinophils per high powered field). There was no significant difference between groups 1 and 2 based on the presence of gastrointestinal complaints, abdominal pain and/or FTT (p>0.05). There was no significant difference between the groups based on the location or presence of an airway abnormality (p>0.05)., Conclusions: Children with recurrent croup and chronic cough may benefit from a multidisciplinary approach to management. Our CARE Team approach led to a specific diagnosis in almost 95% of patients., (Copyright © 2015 Elsevier Ireland Ltd. All rights reserved.)

Croup, or laryngotracheobronchitis, is a common viral respiratory tract illness seen in the pediatric population (). This article describes the case of a child who presents with croup and the characteristic "steeple sign" seen on the radiograph. The patient received a diagnosis of croup secondary to the parainfluenza virus infection. It is imperative for advanced practice nurses to recognize the signs and symptoms of croup when these patient present to emergency care settings. Advanced practice nurses must also consider possible differential diagnoses, accurately interpret the radiographs, and intervene according with supportive care and appropriate management.

Introduction: Croup is characterised by the abrupt onset, most commonly at night, of a barking cough, inspiratory stridor, hoarseness, and respiratory distress due to upper airway obstruction. It leads to signs of upper airway obstruction, and must be differentiated from acute epiglottitis, bacterial tracheitis, or an inhaled foreign body. Croup affects about 3% of children per year, usually between the ages of 6 months and 3 years, and 75% of infections are caused by parainfluenza virus. Symptoms usually resolve within 48 hours, but severe upper airway obstruction can, rarely, lead to respiratory failure and arrest., Methods and Outcomes: We conducted a systematic review and aimed to answer the following clinical questions: What are the effects of treatments in children with mild croup and moderate to severe croup? We searched: Medline, Embase, The Cochrane Library, and other important databases up to November 2013 (Clinical Evidence reviews are updated periodically; please check our website for the most up-to-date version of this review). We included harms alerts from relevant organisations such as the US Food and Drug Administration (FDA) and the UK Medicines and Healthcare products Regulatory Agency (MHRA)., Results: We found 19 studies that met our inclusion criteria. We performed a GRADE evaluation of the quality of evidence for interventions., Conclusions: In this systematic review we present information relating to the effectiveness and safety of the following interventions: corticosteroids (dexamethasone, intramuscular and oral), nebulised budesonide, oral prednisolone, heliox, humidification, and nebulised adrenaline (racemate and L-adrenaline [ephinephrine]).

Recurrent croup is a distinct clinical entity from viral croup. It is not a specific diagnosis and its presence should alert the clinician to explore the underlying cause. We discuss an evidence-based structured approach to management of a child with recurrent croup., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.)

A working knowledge of the legal principles of medical negligence is helpful to neurosurgeons. It helps them to act in a "reasonable, responsible and logical" manner, that is a practice that is consistent with the surgical practice of their peers. This article will review and explain the relevant medical law in relation to duty of care with illustrative neurosurgical cases.

Objectives: Croup is a common childhood respiratory illness that can result in hospitalization and significant morbidity. This study reviewed records of patients hospitalized with croup to determine characteristics associated with increased inpatient treatment and length of stay (LOS)., Methods: Eligible patients were admitted between January 2006 and December 2010 and had discharge diagnosis of croup. Patients were included if they received either racemic epinephrine or systemic corticosteroids during their emergency department or hospital treatment. Patients were excluded for incomplete data on medication or vital signs timing. Hospitalization and treatment decisions were at the discretion of the treating physician., Results: The study analyzed 365 hospitalizations involving 327 patients, 72% male, 62% white, with median age of 16.7 months. Median LOS was 31.7 hours. Patients required racemic epinephrine treatments after hospitalization in 179 cases (49%; mean, 1.33 treatments; range, 0-13; median, 0), and 176 patients (48%) received a dose of systemic corticosteroids after hospital admission. Patients who required racemic epinephrine treatments after hospitalization were indistinguishable from those who did not, based on demographics, past history, or presenting vital signs. Patients with history of croup, history of intubation, or with oxygen saturation <95% on presentation all had increased LOS compared with those without these findings (P < .05)., Conclusions: Fifty-one percent of patients hospitalized with croup did not require inpatient racemic epinephrine treatments. Those with lower oxygen saturations on presentation or past history of croup or intubation were more likely to have prolonged or complicated hospital course.

Providers in pediatric emergency departments (ED) frequently encounter a variety of life-threatening respiratory illnesses. This article reviews current updates on the management and unique adjuncts for 3 common respiratory illnesses. Discussed first is bronchiolitis and the impact of high flow nasal cannula on reducing the need for intubation. Next, the current therapy for croup and the adjunctive use of Heliox and finally, the ED approach to asthma and treatment with breath actuated nebulizers.

Objective: To review the aetiology, investigation, diagnosis, treatment and clinical outcome of children with recurrent croup., Method: Retrospective case note review of all children with recurrent croup referred to the otolaryngology service at our hospital from November 2002 to March 2011., Results: Ninety children with recurrent croup were identified. Twenty-five children (28 per cent) had anatomical airway abnormalities, of which 16 (18 per cent) demonstrated degrees of subglottic stenosis. Twenty-three children (26 per cent) had positive microlaryngobronchoscopy findings suggestive of reflux. Eleven children were treated for gastroesophageal reflux disease, 10 (91 per cent) of whom responded well to anti-reflux medication (p = 0.006). No cause was identified for 41 (45 per cent) of the children; this was the group most likely to continue having episodes of croup at follow up. One death occurred in this group., Conclusion: Airway anomalies are common in children that present with recurrent croup. Laryngobronchoscopy allows identification of the cause of croup and enables a more accurate prognosis. In the current study, laryngobronchoscopy findings that indicated reflux were predictive of benefit from anti-reflux medications, whereas the clinical presentation of reflux was not. Routine measurement of immunoglobulin E and complement proteins did not appear to be helpful.

Objective: Upper airway obstruction is responsive to the reduction in airflow turbulence provided by helium/oxygen (heliox) admixture. Our pediatric critical care transport team (PCCTT) has used heliox for children with upper airway obstruction from croup. We sought to describe our experience with heliox on transport and hypothesized that heliox-treated children with croup would show a more rapid clinical improvement., Methods: Children with croup transported by our PCCTT and admitted to the PICU were evaluated. We analyzed pretransport care, transport interventions, and outcomes. Croup scores (Modified Taussig) were assigned retrospectively according to respiratory therapy charting. Data were analyzed using appropriate statistical tests, including Pearson's chi-square test, Fisher's exact test, Mann-Whitney U rank comparison, and two-sample t-test., Results: Thirty-five children met inclusion criteria. Demographics were similar between groups. The pretransport medical care was similar between groups. Children receiving heliox had a higher baseline croup score [mean (SD) = 5.7(2.3) vs no heliox 2.9 (2.0), P < 0.001]. The improvement in croup scores over the first 60 minutes of transport was more rapid in the heliox-treated children (P < 0.001). There was no difference in the number of children requiring additional nebulized racemic epinephrine during transport. The PICU length of stay (P = 0.59) and hospital length of stay (P = 0.64) were similar between groups., Conclusion: Heliox added to standard transport treatment for critically ill children with croup provides a more rapid improvement in croup scores. Heliox for croup during transport does not prolong intensive care unit stay. A prospective clinical trial is warranted to evaluate heliox in pediatric transport., (Copyright © 2012 Air Medical Journal Associates. Published by Elsevier Inc. All rights reserved.)

This article summarises the five most common lower respiratory tract infections seen in acute care, guiding the nurse in assessment and early recognition of signs of deterioration. A discussion on each condition is provided along with guidance on prevention, advice for parents and on managing patients. This article is intended for students or newly qualified children's nurses, however, it can also serve as a refresher for all professionals working with children.

A single dose of corticosteroids is the first-line treatment for croup, resulting in fewer return visits and hospital admissions, shorter lengths of stay in the emergency department (ED) or hospital, and less need for supplemental medication (strength of recommendation [SOR]: A, meta-analysis and randomized controlled trials [RCTs]). A 0.15 mg/kg dose of oral dexamethasone is as effective as larger doses (SOR: B, small RCTs).Nebulized racemic or L-epinephrine reduces severity of symptoms in moderate-to-severe croup (SOR: C, limited-quality disease-oriented evidence).The role of heliox in moderate to severe croup remains uncertain. Studies to date have been inadequate (SOR: C, limited-quality disease-oriented evidence).Humidified air provides no demonstrable benefit in the acute setting (SOR: A, meta-analysis).

Background: Croup (laryngotracheobronchitis) is a common cause of upper airway obstruction in children with a peak incidence of 60 per 1000 child years in those aged between one and two years. It is characterised by hoarseness, a barking cough, and inspiratory stridor. These symptoms are thought to occur as a result of oedema of the larynx and trachea, which have been triggered by a recent viral infection. Para influenza virus type 1 is the agent most commonly identified in cases of croup. Severe cases are admitted to hospital and steroid treatment is established to reduce disease severity. Treatment with humidified air was previously widely used and is still commonly recommended as home treatment., Objectives: To assess the efficacy of humidified air in the treatment of croup., Search Strategy: We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library Issue 4, 2005), MEDLINE (1966 to January 2006) and EMBASE (1990 to January 2006)., Selection Criteria: Randomised controlled trials (RCTs) involving children suffering from croup treated with humidified air., Data Collection and Analysis: Two authors independently identified potentially relevant abstracts identified from the search and then assessed the full papers for inclusion and methodological quality. Outcome measures included mortality, ventilation, admission to hospital, re-contact with medical services, number of days off school and relief of symptoms; these were separately analysed for the week following treatment. Data extraction was performed by the two authors then entered by one and checked by the second author. Missing data were obtained from trial authors where possible. Data were analysed using Review Manager version 4.2. Sensitivity and sub-group analysis were not possible due to the paucity of trials., Main Results: Three studies in emergency settings provided data on 135 patients with moderate croup for the main outcome (croup score). The combined results from 20 to 60 minutes in the three studies marginally favoured the treatment group with a weighted standardised mean difference of -0.14 (95% confidence interval (CI) -0.75 to 0.47). No other outcomes were significantly different between the groups., Authors' Conclusions: The croup score of children managed in an emergency setting with mild to moderate croup probably does not improve greatly with inhalation of humidified air. Further research is needed in primary care settings, using a wider range of more sensitive outcome measures.