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Croup Is Familiar, Yet Full of Potential Diagnostic and Therapeutic Pitfalls.

Croup is among the most familiar of pediatric problems.

Still, there are some pitfalls worth mentioning.

As we pediatricians know, croup is a viral-induced inflammatory obstruction of the upper airway most often caused by parainfluenza but sometimes resulting from adenovirus or influenza.

Respiratory syncytial virus (RSV) also can cause croup-like symptoms during the winter months.

Croup is in essence a clinical diagnosis.

Although there is no rapid test for parainfluenza, rapid testing for influenza and RSV are available but usually not necessary.

Most pediatricians are intimately familiar with the typical symptoms: stridor and a cough that sounds like barking in a feverish child who has croup-induced upper airway obstruction.

But be careful in your diagnosis. Those same sounds can also arise from trauma, foreign bodies, or bacterial tracheitis-a croup complication.

The upper end of the typical age for croup--1-2 years-is also the age of greatest choking risk.

Taking a thorough history is, of course, essential.

Pay attention to the cough: Croup cough tends to stop and start, while a foreign body cough tends to be more continuous, and intractable.

Diagnostic x-rays are not necessary in children with run-of-the-mill croup.

However, for those sent to the emergency room with worsening airway obstruction and visible retractions, the classic radiographic "steeple sign" reflecting a narrowed laryngeal air column below the vocal cords, appears to be sensitive and specific for croup.

When it comes to management, the tincture of time-about 2 days' worth-works for the vast majority of croupy kids seen in a clinician's office.

Some may benefit from sitting in a steamy bathroom or walking outside in the cool night air, but there have been no studies supporting the use of humidified air delivered into a "croup tent" of a hospitalized child. Rather, they obscure the caretaker's view of the child and may increase, the child's anxiety level, thereby exacerbating breathing problems.

Albuterol is not useful in croup. Neither are antibiotics, unless you're dealing with bacterial tracheitis, a complication that doesn't occur for several days after croup begins.

Steroids, on the other hand, may benefit the small proportion of outpatients who develop mild to moderate stridor at rest with mild retractions but who remain clinically stable. In these children, a single dose of dexamethasone-not five doses-of 0.6 mg/kg may help reduce airway inflammation; the maximum single dose of steroid that you want to give is 8 mg.

Recent data suggest that a single oral steroid dose in your office is as safe and effective as a single injection and may be cheaper to boot. Inhaled steroids work too, but they're often the most expensive choice.

Nebulized racemic epinephrine should be used along with the steroid dose in those children with significant stridor at rest, decreased air entry, and retractions.

In the old days, we used to hospitalize these kids overnight because we were worried about possible rebound.

Today, racemic epinephrine can be given on an outpatient basis, as long as patients can be observed for 2-4 hours after receiving the treatment.

Hospitalization is still recommended for children who live more than 30 minutes from the physician' office, or for those whose home setting is not conducive to careful observation.

Here are two Web sites containing good information about croup for parents: (then click on "croup") and (click on "croup and your child").

DR. MARY ANNE JACKSON is chief of pediatric infectious diseases at Children's Mercy Hospital, Kansas City, and professor of pediatrics at the University of Missouri-Kansas City.

Monitoring a Child With Croup:

1. Mental status. Both agitation and lethargy may signal hypoxia.

2. Presence of barking cough.

3. Degree of inspiratory stridor.

4. Presence of retractions.

5. Presence of hypoxia. Pulse oximetry may be helpful.

6. Air entry. Careful auscultation is important.
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Title Annotation:alternative diagnosis, care of children with croup
Publication:Pediatric News
Article Type:Brief Article
Geographic Code:1USA
Date:Oct 1, 2001
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