• Careful assessment requires looking at the pattern of breathing and limiting interaction to prevent further distressing the child, ensuring a sense of confidence and calmness
• Limit formal examination of the child in the first instance while you obtain crucial information to ascertain how unwell the child is
• The most valuable information can be obtained by observing the child
• Whether the child looks sick or toxic is important in determining the cause of his presentation and differential diagnoses

• Look at the overall appearance and behaviour
  • Is the child sitting up and interacting normally?
  • Is the child agitated or unsettled, as in this case? The child in this scenario would be moderate severity
  • Is the child very agitated, has altered behaviour or drowsy?
• Look at the respiratory rate and effort of breathing
  • If breathing is normal – mild severity
  • If evidence of increased respiratory rate and intercostal muscle use – moderate severity
  • Marked accessory muscle use indicates severe
• Observe the pattern of stridor, which is key to diagnosing croup
  • If a child has mild croup, you may not hear stridor at all, perhaps only when the child is upset or running around
  • Intermittent stridor at rest indicates moderate severity
  • Severe croup is indicated by persistent stridor at rest and the child self-limiting his activity
  • Note: How loud the stridor is does not indicate the severity; it is the presence or absence, and the pattern of stridor which is important
  • If you upset a child with croup, they may develop more stridor and may need a higher level of intervention
  • Part of keeping the child calm is to keep the parents calm
  • Never use a tongue depressor for a child with croup

• Be aware that the most common cause of stridor in children is croup
• When the clinical picture is not typical of croup, and the child appears septic, must consider other causes of upper airway narrowing, for example:
  • Bacterial causes include epiglottitis (can be life threatening, don’t see very often), peritonsillar or retropharyngeal abscess (often can present with a toxic, drooling child who is refusing to move or talk – a medical emergency), and bacterial tracheitis
• These differentials must be considered in children with an atypical picture, those who are not immunised or children who do not fit the classic description of a viral infection

• The pattern is so important in determining what the differential diagnoses are
• For example, a young child with chronic stridor since the first week of life, and not clearly related to a new onset viral infection, other causes need to be considered. In these instances, we recommend referral to a paediatrician, respiratory paediatrician or ENT specialist
• There are other conditions, for example, laryngomalacia or subglottic stenosis or subglottic haemangiomas that can present in this insidious chronic fashion

• Croup is a clinical diagnosis, reliant on clinical observations and the constellation of symptoms of stridor – the hoarse voice, barking cough, the viral prodrome
• There are not any specific investigations that are indicated in the assessment of croup

• In addition to the conservative measures in keeping the child calm, in the first instance give an oral steroid
  • This will reduce the upper airway swelling, and will work quite quickly
  • The two options in this setting would either be prednisolone 1mg/kg oral dose, up to a threshold of 50mg, as a single dose. Alternatively, if oral dexamethasone is available, then we would offer 0.15mg/kg orally, up to a maximum of 12mg as a single dose
• The vast majority of children will take the oral therapy
• We will then observe the child for a minimum of 30 minutes after the steroid is administered, with the expectations that at that time of 30 minutes, if they’re going to respond, you will see some response

• The reason why there are two options is that dexamethasone is not universally available, particularly within community settings. It is generally available in hospitals, and hospital pharmacies can provide a dexamethasone solution
• There is no clear evidence that one is better over the other
• Some parents will say one is better for their child, but either one is appropriate

• If the child has accessory muscle use and still has stridor at rest, or their level of distress they were presenting with at presentation is still present, then it needs to be considered as severe croup
• If at the 30 minute mark there has been no change in those three parameters, then we need to escalate to the severe croup pathway
• We do not know which direction they would go beyond that, and there are a proportion of children that do progress, so the safest is to escalate to the severe croup pathway

• If the child were to improve, and had complete resolution of his stridor at rest, it may be appropriate to send the child home.  However, we would not be sending him home with any cough suppressants.
• There have been many studies on over-the-counter cough suppressants. Cough suppressants have been found to be not helpful, are costly, and are potentially harmful in younger children
• With regards to antibiotics, because viral croup is virally mediated, there is no benefit in giving antibiotics. We would not be giving antibiotics to this child

• The most senior and experienced member is called, usually an intensivist or anaesthetist or paediatrician, to proceed with intubation
• The child would need to be in a well-monitored area, ICU or theatre, to proceed with intubation, usually with a gaseous induction, with the option of having an ENT surgeon to facilitate the intubation and any further treatment that is required

• Croup is common, usually viral in the vast majority, and most children follow the mild to moderate severity of the illness
• For those children who are approaching the more severe range of the condition, the importance of escalating and getting senior involvement early, and following the Therapeutic Guidelines or hospital guidelines is helpful
• A small proportion of children can have other causes of stridor

See eTG: Croup Guidelines, available to eTG complete subscribers. Visit https://www.tg.org.au/