Have you ever heard a child bark like a dog? Most likely everyone has seen a child imitate a dog during playtime when they pretend to walk around on all fours and keep yapping. But, have you ever thought you heard a dog when in fact it was a child coughing? I have. At 2:00 a.m. to be more specific.
Croup doesn’t always come with its’ textbook description of barking like a dog, but when it does, then you know the croup is pretty serious. Croup (a.k.a laryngotracheobronchitis) is caused commonly by the notorious parainfluenza virus and is commoner than you think, but can present anywhere on a spectrum of mild to severe.
Below I’ve discussed a case I encountered as a house officer/intern, when all I could think of was, “What if this is epiglottitis?” I’ll tell you why it wasn’t at the end – my consultant was nice enough to bug me gloriously about it for a couple of days.
So what happened?
I was woken up at 2:00 a.m. by the nurse when a 3-year-old boy was admitted with noisy breathing and a croaky cough for the past 2 days. Whilst taking the history, it was a typical respiratory tract kind of presentation, however, the parents said the child seemed to have difficulty breathing. I didn’t think too much of it because the child looked relatively well and not in respiratory distress. I was beginning to think the parents had been overreacting until the child began to cough. And by cough I mean bark. This alerted me to think of croup.
What did you do?
The child was too well-looking for it to be epiglottitis, but I still ruled out the specific symptoms for epiglottitis. The mother mentioned that the child had a mild fever that settled with paracetamol and was consuming food and drink as normal. The child also had no drooling, but sometimes found it difficult to breathe which had alerted the mother. The child had received all his appropriate vaccinations. The mother said the cough and fever had an insidious onset and does not think that her child could have accidentally inhaled a foreign body.
On examination, the child was warm to touch. He was slightly tachycardic, but blood pressure was appropriate for the age. Oxygen saturation was maintained at 97%, but the child had a respiratory rate of 24 breaths/min with no cyanosis. The child had no subcostal/intercostal recessions and no tracheal tug. Chest expansion was symmetrical and auscultation was normal. Occasionally a stridor was heard.
Management
As the child was comfortable with his mother, I did not want to disturb him too much. Using the Westley croup score, I deemed the child to have moderate croup. Paracetamol was given for the fever and the mother was asked to do some steam inhalation with the little boy (steam inhalation is now no longer recommended as a recent systematic review did not find any beneficial effect). Oral dexamethasone was then given at a dose of 0.15 mg/kg BD. The child was then kept overnight for observation and discharged the next day.
Possible score 0-17: 0-3 = mild croup, 4-6 = moderate croup, >6 =severe croup. Source: Emedicine
Case courtesy of Dr Michael Sargent,<a href=”https://radiopaedia.org/”>Radiopaedia.org</a>. From the case <a href=”https://radiopaedia.org/cases/6086″>rID: 6086</a>ption
No investigations are required for the management of croup as you must do as little as possible to disturb the child. A radiological sign known as “steeple sign” can be seen on an anteroposterior neck x-ray, but this is rarely done because it is unnecessary to put a child through it – clinical diagnosis, not radiological! Anyway, in a child with the croup, the x-ray will show subglottic tracheal narrowing which is in the shape of a church steeple – hence the name Steeple’s sign (see below).
Discussion
Croup is not overly common in Sri Lanka but does now and again make an appearance. It is common in children between 6 months and 3 years and can be spread via close contact.
Epiglottitis and foreign body obstruction are the primary differential diagnoses of croup and this is what you need to rule out. In Sri Lanka, the immunization schedule is pretty amazing and has good coverage so epiglottitis caused by the Haemophilus influenza Bacteria could be easily excluded as the vaccine is present in the immunization schedule.
An easy table to remember Croup vs. Epiglottitis (and additionally Bronchiolitis
Using the Westley score, you need to assess if the croup is mild, moderate or severe as this changes the management. Mild croup can be managed at home as it is self-limiting and except for paracetamol and good fluid intake, it does not need much else in terms of management. If oxygen saturation is low, supplementary oxygen therapy can be given. Oral dexamethasone (0.15mg/kg is the international consensus but there is a Sri Lankan guideline stating 0.6mg/kg so check with a senior) or oral prednisolone (1-2 mg/kg) or nebulised budesonide (2mg) has been found to be effective in reducing symptoms. In severe cases, nebulised adrenaline (0.4 mg/kg up to 5 mg of 1:1000) quickly relieves symptoms and can be repeated if required every half an hour.
You must explain to the parents that there is no need for antibiotics as it is a viral infection. Cough medicine is also not advised as it can make the child drowsy.
It is very rare that children with croup are so severe that they require hospitalization, but secondary bacterial infections such as pneumonia may occur.
Conclusion
Even though I was confident in my management of croup, I was a little petrified the entire night that the patient could have epiglottitis much to my consultant’s amusement the next day. I didn’t prick the child, but as a little uncertain intern, I was still freaking out a little bit. What I learnt, however, was that due to the effective immunization programme in Sri Lanka, epiglottitis is very rare in Sri Lanka.
Here is a small schematic flow diagram published from the Sri Lanka National Guideline on the Management of Respiratory tract infections in Children.
From the Sri Lanka National Guideline on the Management of Respiratory tract infections in Children
