Croup (Laryngotracheobronchitis) in Children
Stridor (Upper Airways Obstruction)
J05.0-1
DESCRIPTION
- Croup is a common cause of potentially life-threatening airway obstruction in childhood. It is characterised by inflammation of the larynx, trachea and bronchi. Most common causative pathogens are viruses, including measles
- A clinical diagnosis of viral croup can be made if a previously healthy child develops progressive inspiratory airway obstruction with stridor and a barking cough, 1–2 days after the onset of an upper respiratory tract infection. A mild fever may be present
- Suspect foreign body aspiration if there is a sudden onset of stridor in an otherwise healthy child
- Suspect epiglottitis if the following are present in addition to stridor:
- Very ill child
- High fever
- Sitting upright with head held erect
- Drooling saliva
- Unable to swallow
Assessment of the severity of airway obstruction and management in croup
| Grade 1 Inspiratory stridor only |
- Corticosteroids (intermediate-acting) e.g.: - Prednisone, oral, 1–2 mg/kg, single dose - Do not give if measles or herpes infection present. - Refer LoE:III31 |
| Grade 2 Inspiratory and expiratory stridor |
- Corticosteroids (intermediate-acting) e.g.: - Prednisone, oral, 1–2 mg/kg, immediately as a single dose LoE:III32 - Adrenaline, 1:1000 diluted in sodium chloride 0.9%, nebulised, immediately - Dilute 1 mL of 1:1000 adrenaline with 1 mL sodium chloride 0.9% - Repeat every 15–30 minutes until expiratory stridor disappears - Refer |
| Grade 3 Inspiratory and expiratory stridor with active expiration, using abdominal muscles |
- Treat as above - If no improvement within one hour, refer urgently (intubate before referral if possible) |
| Grade 4 Cyanosis, apathy, marked retractions, impending apnoea |
- Intubate (if not possible give treatment as above) - Refer urgently |
GENERAL MEASURES
- Keep child comfortable
- Continue oral fluids provided that patient is able to swallow
- Encourage parent or caregiver to remain with the child
MEDICINE TREATMENT
- Paracetamol, oral, 10–15 mg/kg/dose 6 hourly when required. See: dosing table
Children grade 2 or more stridor-while awaiting transfer:
- Corticosteroids (intermediate-acting) e.g.:
- Prednisone, oral, 1–2 mg/kg immediately as a single dose
- Adrenaline (epinephrine), 1:1000, nebulised, immediately using a nebuliser
- If there is no improvement, repeat every 15 minutes until the child is transferred
- Dilute 2 mL of 1:1000 adrenaline with 2 mL sodium chloride 0.9%
- Nebulise the entire volume with oxygen at a flow rate of 6–8 L/minute
LoE:IVb33
Weight-based prednisone dosing for children < 18 kg:
|
Weight |
Dose |
Tablet |
Age |
|
>11–14 kg |
20 mg |
4 tablets |
>2–3 years |
|
>14–17.5 kg |
30 mg |
6 tablets |
>3–5 years |
If epiglottitis suspected:
- Ceftriaxone, IM, 80 mg/kg/dose immediately as a single dose and refer. See: dosing table
- Do not inject more than 1 g at one injection site
|
CAUTION: USE OF CEFTRIAXONE IN NEONATES AND CHILDREN - If SUSPECTING SERIOUS BACTERIAL INFECTION in neonate, give ceftriaxone, even if jaundiced - Always include the dose and route of administration of ceftriaxone in the referral letter |
Management during transfer:
- Give the child oxygen to keep oxygen saturation levels at 93-95%
- Continue nebulisations with adrenaline
- If grade 2-3, contact ambulance or nearest doctor
- If grade 4, intubate and transfer
REFERRAL
Urgent
- Cildren with:
- Grade 2-4 stridor
- Chest indrawing
- Rapid breathing
- Altered consciousness
- Inability to drink or feed
- For confirmation of diagnosis
- Suspected foreign body
- Suspected epiglottitis
Non Urgent
- All children grade 1 stridor
Standard Treatment Guidelines and Essential Medicines List for South Africa, Primary Healthcare, 2020-4-Version 1.0_16 September 2024
Chapter 17: Respiratory Conditions_17.2. Stridor (Upper Airways Obstruction)_17.2.1. Croup (Laryngotracheobronchitis) in Children