Croup
Croup - Summary
Croup (laryngotracheitis) is a common childhood disease that is usually caused by a virus. It is characterized by the sudden onset of a seal-like barking cough usually accompanied by stridor (predominantly inspiratory), hoarse voice, and respiratory distress due to upper airways obstruction. Symptoms are usually worse at night. There may be a fever up to 40°C.
There is often a preceding 1–4-day history of a non-specific cough, rhinorrhoea, and fever.
Croup most commonly affects children 6 months to 3 years of age, with a peak incidence during the second year of life.
Mild:
Occasional barking cough and no audible stridor at rest.
No or mild suprasternal and/or intercostal recession.
The child is happy and is prepared to eat, drink, and play.
Moderate:
Frequent barking cough and easily audible stridor at rest.
Suprasternal and sternal wall retraction at rest.
No or little distress or agitation.
The child can be placated and is interested in its surroundings.
Severe:
Frequent barking cough with prominent inspiratory (and occasionally, expiratory) stridor at rest.
Marked sternal wall retractions.
Significant distress and agitation, or lethargy or restlessness (a sign of hypoxaemia).
Tachycardia occurs with more severe obstructive symptoms and hypoxaemia.
Impending respiratory failure may develop regardless of the severity of the symptoms:
Change in mental state, such as lethargy and listlessness or decreased level of consciousness.
Dusky appearance.
Tachycardia.
In children with impending respiratory failure, breathing may be laboured, a barking cough may not be prominent, stridor at rest may be hard to hear, and sternal wall retractions may not be marked. A child who appears to be deteriorating but whose stridor appears to be improving has worsening airways obstruction and is at high risk of complete airway occlusion.
A child should be immediately admitted when presenting with:
Moderate or severe croup, or impending respiratory failure.
A serious disorder such as epiglottitis, bacterial tracheitis, peritonsillar abscess, retropharyngeal abscess, foreign body or angioneurotic oedema.
Mild croup can usually be managed at home. However, reasons for admission include: a history of severe obstruction, age less than 6 months, immunocompromised, an inadequate fluid intake, an uncertain diagnosis, a poor response to initial treatment, parental anxiety, no transport, or living far from the hospital.
All children with mild, moderate, or severe croup should receive a single dose of oral dexamethasone (0.15 mg per kg body weight).
Oral prednisolone (1–2 mg per kg body weight) is an alternative if dexamethasone is not available. A second dose should be considered if residual symptoms of stridor are still present the following day.
Croup is self limiting and symptoms usually resolve within 48 hours. The use of paracetamol or ibuprofen to control fever and pain should be advised, and arrangements made to review the child within a few hours. Parents should be advised to seek urgent medical advice if there is any deterioration.
Have I got the right topic?
This CKS topic covers the management of croup in primary care.
This CKS topic does not cover the management of croup in secondary care, nor the use of nebulized adrenaline.
There are separate CKS topics on Common cold, Feverish children - risk assessment, and Sore throat - acute.
The target audience for this CKS topic is healthcare professionals working within the NHS in the UK, and providing first contact or primary health care.
How up-to-date is this topic?
How up-to-date is this topic?
Changes
September 2012 — reviewed. A literature search was conducted in September 2012 to identify evidence-based guidelines, UK policy, systematic reviews, and key RCTs published since the last revision of the topic. No changes to clinical recommendations have been made.
Previous changes
July 2011 — minor update. More exact paracetamol dosing for children has been introduced by the Medicines and Healthcare products Regulatory Agency [MHRA, 2011]. Prescriptions have been updated to reflect the revised dosing. Issued in July 2011.
June to September 2008 — this is a new CKS topic. The evidence-base has been reviewed in detail, and recommendations are clearly justified and transparently linked to the supporting evidence.
Update
New evidence
Evidence-based guidelines
No new evidence-based guidelines since 1 September 2012.
HTAs (Health Technology Assessments)
No new HTAs since 1 September 2012.
Economic appraisals
No new economic appraisals relevant to England since 1 September 2012.
Systematic reviews and meta-analyses
No new systematic reviews since 1 September 2012
Primary evidence
No new randomized controlled trials published in the major journals since 1 September 2012.
New policies
No new national policies or guidelines since 1 September 2012.
New safety alerts
No new safety alerts since 1 September 2012.
Changes in product availability
No changes in product availability since 1 September 2012.
Goals and outcome measures
Goals
Making an accurate assessment of the severity of the illness
Appropriate treatment in primary care settings
Appropriate referral to secondary care or other specialist service
Providing appropriate advice to parents
Background information
Definition
What is it?
Croup (laryngotracheitis) is a common childhood disease that is usually caused by a virus. It is characterized by the sudden onset of a seal-like barking cough that is usually accompanied by stridor (predominantly inspiratory), hoarse voice, and respiratory distress due to upper airways obstruction. Symptoms are usually worse at night. There may be a fever up to 40°C.
There is often a preceding 1–4-day history of a non-specific cough, rhinorrhoea, and fever.
[Fitzgerald, 2006; Alberta Medical Association, 2008; Bjornson and Johnson, 2008]
Prevalence
How common is it?
Croup most commonly affects children 6 months to 3 years of age, with a peak incidence during the second year of life. It can however affect children as young as 3 months of age, or adolescents and, very rarely, adults.
[Fitzgerald, 2006; Alberta Medical Association, 2008; Bjornson and Johnson, 2008]
Management
Management
Scenario: Croup
Scenario: Croup
Assessment
How should I assess someone with croup?
Assess the severity of the symptoms:
Mild:
Occasional barking cough and no audible stridor at rest.
No or mild suprasternal and/or intercostal recession.
The child is happy and is prepared to eat, drink, and play.
Moderate:
Frequent barking cough and easily audible stridor at rest.
Suprasternal and sternal wall retraction at rest.
No or little distress or agitation.
The child can be placated and is interested in its surroundings.
Severe:
Frequent barking cough with prominent inspiratory (and occasionally, expiratory) stridor at rest.
Marked sternal wall retractions.
Significant distress and agitation, or lethargy or restlessness (a sign of hypoxaemia).
Tachycardia occurs with more severe obstructive symptoms and hypoxaemia.
Impending respiratory failure may develop regardless of the severity of the symptoms:
The presence of any of these signs overrides any other clinical signs:
Change in mental state, such as lethargy and listlessness or decreased level of consciousness.
Pallor.
Dusky appearance.
Tachycardia.
In children with impending respiratory failure, breathing may be laboured, a barking cough may not be prominent, stridor at rest may be hard to hear, and sternal wall retractions may not be marked.
A child who appears to be deteriorating but whose stridor appears to be improving has worsening airways obstruction and is at high risk of complete airway occlusion.
Basis for recommendation
Basis for recommendation
A clinically useful severity-assessment table has been developed by the Alberta Clinical Practice Guideline working group; the CKS recommendations are based on this [Alberta Medical Association, 2008] and on expert opinion in review articles [Cherry, 2005; Brown, 2006].
Admission
Who should I admit?
Rarely, serious diseases may present with respiratory distress and stridor. Arrange immediate admission to hospital if you suspect a serious disorder:
Caused by infection: epiglottitis, bacterial tracheitis, peritonsillar abscess, retropharyngeal abscess, or laryngeal diphtheria.
Not caused by infection: foreign body, angioneurotic oedema, hypocalcaemic tetany, or ingestion of corrosives.
Immediately admit a child who has moderate or severe croup, or impending respiratory failure.
Most children will have mild croup, which can be managed at home. However, consider admission to hospital if any of the following are present. The child:
Has a history of severe obstruction, or previous severe croup, or known structural upper airways abnormalities (e.g. laryngomalacia, tracheomalacia, vascular ring, Down's syndrome); these increase the risk of severe croup developing.
Is less than 6 months of age.
Is immunocompromised.
Has inadequate fluid intake, or is refusing liquids.
Has a poor response to initial treatment.
Has an uncertain diagnosis.
Or if there is significant parental anxiety, late evening or night-time presentation, the child's home is a long way from the hospital, or the parents have no transport.
Basis for recommendation
Basis for recommendation
The recommendations regarding assessment of severity and admission are based on expert opinion in guidelines [Alberta Medical Association, 2008], review articles [Cherry, 2005; Brown, 2006; Fitzgerald, 2006; Bjornson and Johnson, 2008], clinical practice guidelines [Sydney West Area Health Service, 2004], and a text book [Helms and Henderson, 2003]. The most important issue is the maintenance of the airway — if there is any risk of the child developing acute obstruction then they must be admitted to hospital urgently [Brown, 2006].
There is little evidence to guide clinicians about which children should be admitted to hospital. A study of children (n = 527) admitted to hospital with stridor and/or sternal retractions at rest showed that only 1% of those who had resting stridor but no sternal retraction (n = 305) had worsening respiratory distress after admission [Wagener et al, 1986].
A child with croup may be pyrexial but should not drool or be toxic (pale, very febrile, and poorly perfused) [Fitzgerald, 2006], and agitation is usually absent in croup [Brown and Klassen, 2000].
Treatment
How should I treat a child with croup?
Give all children with mild, moderate, or severe croup a single dose of oral dexamethasone (0.15 mg per kg body weight). If it is not possible to weigh the child then as a rough guide the dose would be 1.5–2 mg for a child of average size aged 12–15 months and 2–3 mg for a child of average size aged 3–4 years.
Providers of urgent care services should ensure that dexamethasone is available.
Oral prednisolone (1–2 mg per kg body weight) is an alternative if dexamethasone is not available. Consider giving a second dose if residual symptoms of stridor are still present the following day.
Basis for recommendation
Basis for recommendation
There is good evidence from a Cochrane systematic review that corticosteroids are beneficial in children with mild, moderate, and severe croup.
Oral administration of dexamethasone is preferred, as there is evidence that it is at least as effective as intramuscular dexamethasone or nebulized budesonide, and oral administration is less traumatic for the child. Although there are no published trials comparing single- and multiple-dose regimens of dexamethasone in croup, the short history of the disease suggests that a single dose should be sufficient [Bjornson and Johnson, 2008].
There is conflicting evidence regarding whether prednisolone is as effective as dexamethasone. Oral dexamethasone may reduce the need for additional medical attention compared to prednisolone. Expert reviewers suggested a repeat dose of prednisolone the following day particularly if there are any residual symptoms of stridor.
CKS has recommended the use of the lower dose (0.15 mg per kg) of dexamethasone. A dose of 0.6 mg per kg has been used traditionally and there is more evidence for the use of this dose. However evidence from four randomized controlled trials showed no difference in primary outcome measures between doses of 0.15 mg per kg body weight, and 0.6 mg per kg body weight. Advice from the British National Formulary (BNF) and expert opinion is that a dose of 0.15 mg per kg body weight is sufficient. The BNF recommends using a dose of 0.15 mg per kg in children with mild croup and also giving this dose to children who are being admitted to hospital [BNF 64, 2012]
If prednisolone is used the BNF recommends a dose of 1–2 mg per kg body weight [BNF 64, 2012].
Although steroid treatment of children with croup is generally well tolerated, concerns exist about possible adverse events. There are limited data on harms because of the small sample size in all available studies [Cherry, 2005], but no adverse effects have been associated with the use of corticosteroids in children with croup [Bjornson and Johnson, 2008].
Advice for parents
What advice should I give to parents?
Explain that croup is self limiting and symptoms usually resolve within 48 hours, although occasionally they may last for up to a week. Resolution of croup symptoms is usually followed by symptoms of upper respiratory tract infection.
Advise the use of paracetamol or ibuprofen to control fever and pain:
Do not over- or under-dress a child with fever.
Tepid sponging is not recommended.
Do not routinely give antipyretic drugs to a child with fever with the sole aim of reducing body temperature.
Ensure an adequate fluid intake.
Do not advise humidified air (e.g. steam inhalation).
Arrange to review the child within a few hours, either by face-to-face consultation or by telephone. Advise parents to seek urgent medical advice:
If there is progression from mild to moderate airways obstruction, such as development of intermittent stridor at rest or increased effort of breathing (chest and suprasternal indrawing), as the child may need to be observed in hospital.
If the child becomes toxic (pale, very high fever, tachycardic) as this may mean the child has an alternative diagnosis (e.g. bacterial tracheitis or epiglottitis).
Advise the parents to call for an emergency ambulance if the child:
Becomes cyanosed.
Is unusually sleepy.
Is struggling to breathe.
Explain that cough medicines, decongestants, and short-acting beta-agonists are not effective. Croup is usually a viral illness and antibiotics are not needed.
Basis for recommendation
Basis for recommendation
These recommendations are based on expert advice from the Alberta Medical Association guidelines [Alberta Medical Association, 2008], review articles [Fitzgerald, 2006; Vyas, 2007], and a text book [Brown and Klassen, 2000].
The advice on managing fever is based on recommendations by the National Institute for Health and Clinical Excellence [NICE, 2007].
Although there are no published controlled studies regarding the use of analgesics and antipyretics in children with croup, it is reasonable to suppose that they will reduce fever and pain [Alberta Medical Association, 2008].
CKS found no evidence to support the use of humidified air in the treatment of croup; there is no benefit.
CKS found no rationale for the use of cough medicines, decongestants, or short acting beta-agonists [Bjornson and Johnson, 2008].
CKS found no controlled trials on the potential benefits of antibiotics in a child with croup; as croup is almost always a viral illness their use is not rational [Alberta Medical Association, 2008]. Superinfections, such as bacterial tracheitis and pneumonia, occur in less than 1/1000 children with croup and prophylactic antibiotics should not be used [Bjornson and Johnson, 2008].
Evidence
Evidence
Supporting evidence
Effectiveness of corticosteroids
Evidence on the effectiveness of corticosteroids in a child with croup
CKS found good evidence that corticosteroids are beneficial in children with mild, moderate, and severe croup:
A Cochrane review investigated the use and effectiveness of glucocorticoids in the treatment of children with croup [Russell et al, 2011]:
Studies included were randomized controlled trials that studied children with croup and objectively measured the effectiveness of glucocorticoid treatment. Thirty-eight studies met the inclusion criteria (n = 4299).
Glucocorticoid treatment was associated with an improvement in the Westley croup score at 6 hours (weighted mean difference [WMD] –1.2, 95% CI –1.6 to –0.8) and at 12 hours (WMD –1.9, 95% CI –2.4 to –1.3); at 24 hours this improvement was no longer significant (WMD –1.3, 95% CI –2.7 to +0.2).
There were fewer return visits and/or readmissions in children treated with glucocorticoids (RR 0.50, 95% CI 0.36 to 0.70).
The length of time spent in Accident and Emergency or hospitalized (WMD 12 hours, 95% CI 5 to 19) was significantly less for children treated with glucocorticoids.
There was less use of epinephrine in children treated with a glucocorticoid (risk difference [the risk in one group minus the risk in the other] 10%, 95% CI 1 to 20).
The authors concluded that:
Dexamethasone and budesonide are effective in relieving the symptoms of croup as early as 6 hours after treatment.
Dexamethasone is also effective in mild croup populations.
A randomized double blind placebo-controlled trial of children with mild croup (n = 720) [Bjornson et al, 2004] compared children given one dose of oral dexamethasone (0.6 mg per kg body weight) with placebo.
In the dexamethasone group:
Return to medical care was significantly lower (7.3% versus 15.3%, p < 0.001).
There was quicker resolution of croup symptoms (p = 0.003).
There was less lost sleep (p < 0.001).
There was less parental stress (p < 0.001).
Among the 720 children, there were no cases of gastrointestinal bleeding, complicated varicella, or bacterial tracheitis. There were seven cases of pneumonia (of which three were in the dexamethasone group).
The authors concluded that in children with mild croup:
Dexamethasone is an effective treatment that results in consistent and small but important clinical and economic benefits.
Although the long-term effects of this treatment are not known, the data support the use of dexamethasone in most, if not all, children with croup.
Choice of oral corticosteroid: dexamethasone or prednisolone
Evidence on the choice of oral corticosteroid: dexamethasone or prednisolone
Oral dexamethasone may reduce the need for additional medical attention compared with prednisolone but CKS found conflicting evidence.
CKS found two double-blind randomized controlled trials comparing dexamethasone and prednisolone in children with croup.
A randomized double-blind trial of children with mild-to-moderate croup (n = 133) received a single oral dose of either prednisolone (1 mg per kg body weight) or dexamethasone (0.15 mg per kg) [Sparrow and Geelhoed, 2006].
Both were equally effective when first given.
Fewer children who received dexamethasone re-attended for further medical care compared with prednisolone (7.4% versus 29.32%, 95% CI 3 to 13, p < 0.01).
There was no significant difference between the groups regarding those admitted to hospital, or the time spent in the hospital Emergency department, or the duration of croup symptoms.
Initially dexamethasone and prednisolone were equally effective but more children relapsed on prednisolone and attended for further medical care. The authors queried whether this difference reflected the shorter half life of prednisolone and suggested that a two day course of prednisolone 1 mg per kg may be justified.
A prospective, double-blind, randomized trial compared three corticosteroid regimens in children with mild-to-moderate croup (n = 99) [Fifoot and Ting, 2007].
The participants were randomized to receive a single oral dose of either prednisolone 1 mg per kg body weight (n = 34), dexamethasone 0.15 mg per kg (n = 34), or dexamethasone 0.6 mg per kg (n = 31).
Primary outcome measures were the magnitude and rate of reduction in the Westley croup score; the study was powered for this.
Secondary outcome measures were the proportion of subjects requiring admission or salvage therapy, such as nebulized adrenaline, during the initial presentation.
However the study was not powered to detect differences in re-presentation rates for further medical care.
There were no significant differences in primary or secondary outcome measures between the three treatment groups.
Dosage and route of administration of dexamethasone
Evidence on the dosage and route of administration of dexamethasone
Oral administration of dexamethasone is preferred, as there is evidence that it is at least as effective as intramuscular dexamethasone or nebulized budesonide. There is good evidence that a dose of 0.6 mg per kg dexamethasone is effective in mild, moderate and severe croup and also evidence that a dose of dexamethasone 0.15 mg per kg body weight is sufficient.
A non-systematic review [Bjornson and Johnson, 2008] investigated the route of administration of corticosteroids and concluded that:
The oral or intramuscular route is either equivalent to, or superior to, inhalation.
Oral dexamethasone is as effective as intramuscular dexamethasone.
A dexamethasone dose of 0.6 mg per kg has been most commonly studied. 31 of the 38 studies included in a Cochrane review [Russell et al, 2011] studied dexamethasone.
A meta-analysis of nine studies concluded that the higher the dose of corticosteroid given, the greater the number of hospitalised children who responded to treatment compared with placebo. In seven of these studies dexamethasone was given and prednisolone or methylprednisolone were used in the others but to allow comparison all doses were converted to cortisone dose equivalents [Kairys et al, 1989].
A large randomized double blind placebo-controlled trial of children with mild croup (n = 720) [Bjornson et al, 2004] found that dexamethasone in a dose of 0.6 mg per kg was effective in children with mild croup.
A non-systematic review [Bjornson and Johnson, 2008] that found four randomized controlled trials comparing doses of dexamethasone (all with small sample sizes), showed no difference in primary outcome measures between doses of 0.15 mg per kg body weight, 0.3 mg per kg body weight, and 0.6 mg per kg body weight:
One study (n = 120) of hospitalised children with croup compared doses of dexamethasone 0.15 mg per kg, 0.3 mg per kg and 0.6 mg per kg and found no significant difference between the groups [Geelhoed and Macdonald, 1995]. This study may have been too small to detect a clinically important difference in efficacy between the higher and lower dose groups [Brown, 2002].
One study (n = 99) compared doses of oral dexamethasone 0.15 mg per kg, 0.6 mg per kg and prednisolone 1 mg per kg and found no difference between the three groups at follow up after 4 hours [Fifoot and Ting, 2007]. This study was not powered to detect any difference in representation rates.
One study (n = 72) in Saudi Arabia compared a dose of oral dexamethasone (0.15 mg per kg) with a dose of 0.6 mg per kg and found no difference in admission rates or median hospital stay [Alshehr et al, 2005].
One study (n = 41) used intravenous dexamethasone 0.6 mg per kg or 0.15 mg per kg and found no difference between the groups at 8 hours [Chub-Uppakarn and Sangsupawanich, 2007].
One study (n = 100) compared outpatient treatment with a single dose of 0.15 mg dexamethasone with placebo and found that dexamethasone reduced the risk of needing further medical care (p < 0.01) [Geelhoed et al, 1996].
Use of humidified air inhalation
Evidence on the use of humidified air inhalation for treating croup
CKS found no evidence to support the use of humidified air in the treatment of croup; there is no benefit, and there is a risk of harm.
A Cochrane review aimed to assess the efficacy of humidified air in the treatment of croup [Moore and Little, 2006]:
The authors searched the Cochrane Central Register of Controlled Trials, Medline, and Embase and included randomized controlled trials with or without blinding. All studies treating children with a clinical diagnosis of croup with warm or cool humidified air delivered by steam or humidified tent were eligible, whether inpatients, attenders at the Emergency department, or in the community.
Three studies in emergency settings met the inclusion criteria and provided data on children with moderate croup (n = 135) for the main outcome (croup score).
Results from two of these studies which assessed children at 60 minutes and one study which assessed children at 20 minutes were combined. The combined results marginally favoured the treatment group, with a weighted standardized mean difference of –0.14 (95% CI –0.75 to +0.47). None of the outcomes were significantly different between the groups.
The authors concluded that children with mild-to-moderate croup managed in an emergency setting probably do not improve greatly with the inhalation of humidified air. There was insufficient evidence to exclude either a small beneficial or a small harmful effect.
There were no studies in the primary care setting regarding the use of warm humidified air [Moore and Little, 2007].
Studies did not take into account the particle size of the humidified water. There is a possibility that the size of water particles obtained by standard methods of humidification may cause them to be deposited in the nose and mouth and not reach the larynx. A randomized, single-blind, controlled trial of children with moderate croup (n = 140) compared standard blow-by humidification (commonly used placebo), controlled delivery of 40% humidity (optimally delivered placebo), and 100% humidification containing particle size of theoretical benefit. There was no difference in symptom scores between the groups [Scolnik et al, 2006].
A structured review commented on the potential difficulties with administration of humidified air [Bjornson and Johnson, 2008]:
Hot humidified air can cause scalds [Greally et al, 1990].
Mist tents can disperse moulds and fungus into the environment unless they are properly cleaned.
Mist tents are cold and wet and separate the child from the parents, which usually causes the child to become agitated and may worsen their symptoms.
Search strategy
Scope of search
A literature search was conducted for guidelines and systematic reviews on primary care management of croup.
Search dates
June 2008 — September 2012
Key search terms
Various combinations of searches were carried out. The terms listed below are the core search terms that were used for Medline and these were adapted for other databases. Further details are available on request
exp Croup/, croup.tw., laryngotracheobronchitis.tw., laryngotracheitis.tw.
Table 1. Key to search terms.| Search commands | Explanation |
|---|---|
| / | indicates a MeSh subject heading with all subheadings selected |
| .tw | indicates a search for a term in the title or abstract |
| exp | indicates that the MeSH subject heading was exploded to include the narrower, more specific terms beneath it in the MeSH tree |
| $ | indicates that the search term was truncated (e.g. wart$ searches for wart and warts) |
Sources of guidelines
National Institute for Health and Clinical Excellence (NICE)
Scottish Intercollegiate Guidelines Network (SIGN)
Royal College of General Practitioners
National Guidelines Clearinghouse
Guidelines International Network
NHS Scotland National Patient Pathways
Agency for Healthcare Research and Quality
Institute for Clinical Systems Improvement
National Health and Medical Research Council (Australia)
Royal Australian College of General Practitioners
British Columbia Medical Association
University of Michigan Medical School
Michigan Quality Improvement Consortium
National Resource for Infection Control
UK Ambulance Service Clinical Practice Guidelines
RefHELP NHS Lothian Referral Guidelines
Medline (with guideline filter)
Driver and Vehicle Licensing Agency
NHS Health at Work (occupational health practice)
Sources of systematic reviews and meta-analyses
Systematic reviews
Protocols
Database of Abstracts of Reviews of Effects
Medline (with systematic review filter)
EMBASE (with systematic review filter)
Sources of health technology assessments and economic appraisals
NIHR Health Technology Assessment programme
NHS Economic Evaluations
Health Technology Assessments
Canadian Agency for Drugs and Technologies in Health
International Network of Agencies for Health Technology Assessment
Sources of randomized controlled trials
Central Register of Controlled Trials
Medline (with randomized controlled trial filter)
EMBASE (with randomized controlled trial filter)
Sources of evidence based reviews and evidence summaries
Central Services Agency COMPASS Therapeutic Notes
Sources of national policy
Health Management Information Consortium (HMIC)
Patient experiences
Patient.co.uk - Patient Support Groups
Sources of medicines information
The following sources are used by CKS pharmacists and are not necessarily searched by CKS information specialists for all topics. Some of these resources are not freely available and require subscriptions to access content.
British National Formulary (BNF)
electronic Medicines Compendium (eMC)
European Medicines Agency (EMEA)
References
Alberta Medical Association (2008) Guideline for the diagnosis and management of croup. ..Alberta Medical Association.www.topalbertadoctors.org [Free Full-text]
Alshehr, M., Almegamsi, T. and Hammdi, A. (2005) Efficacy of a small dose of oral dexamethasone in croup. Biomedical Research 16(1), 65-72.
Bjornson, C.L. and Johnson, D.W. (2008) Croup. Lancet 371(9609), 329-339. [Abstract]
Bjornson, C.L., Klassen, T.P., Williamson, J. et al. (2004) A randomized trial of a single dose of oral dexamethasone for mild croup. New England Journal of Medicine 351(13), 1306-1313. [Abstract] [Free Full-text]
BNF 64 (2012) British National Formulary. 64th edn. London: British Medical Association and Royal Pharmaceutical Society of Great Britain.
Brown, J.C. (2002) The management of croup. British Medical Bulletin 61(1), 189-202. [Abstract] [Free Full-text]
Brown, S. (2006) GP guide to the assessment and management of croup. Prescriber 17(16), 25-28. [Free Full-text]
Brown, J.C. and Klassen, T.P. (2000)
Cherry, J.D. (2005) State of the evidence for standard-of-care treatments for croup: are we where we need to be? Pediatric Infectious Disease Journal 24(11 Suppl), S198-S201. [Abstract]
Chub-Uppakarn, S. and Sangsupawanich, P. (2007) A randomized comparison of dexamethasone 0.15 mg/kg versus 0.6 mg/kg for the treatment of moderate to severe croup. International Journal of Pediatric Otorhinolaryngology 71(3), 473-477. [Abstract]
Fifoot, A.A. and Ting, J.Y. (2007) Comparison between single-dose oral prednisolone and oral dexamethasone in the treatment of croup: a randomized, double-blinded clinical trial. Emergency Medicine Australasia 19(1), 51-58. [Abstract]
Fitzgerald, D.A. (2006) The assessment and management of croup. Paediatric Respiratory Reviews 7(1), 73-81. [Abstract]
Geelhoed, G.C. and Macdonald, W.B. (1995) Oral dexamethasone in the treatment of croup: 0.15 mg/kg versus 0.3 mg/kg. Pediatric Pulmonology 20(6), 362-368. [Abstract]
Geelhoed, G.C., Turner, J. and Macdonald, W.B.G. (1996) Efficacy of a small single dose of oral dexamethasone for outpatient croup: a double blind placebo controlled trial. British Medical Journal 313(7050), 140-142. [Abstract] [Free Full-text]
Greally, P., Cheng, K., Tanner, M.S. and Field, D.J. (1990) Children with croup presenting with scalds. British Medical Journal 301(6743), 113. [Free Full-text]
Helms, P. and Henderson, J. (2003)
Kairys, S.W., Olmstead, E.M. and O'Connor, G.T. (1989) Steroid treatment of laryngotracheitis: a meta-analysis of the evidence from randomized trials. Pediatrics 83(5), 683-693. [Abstract]
MHRA (2011) Press release: more exact paracetamol dosing for children to be introduced. ..Medicines and Healthcare products Regulatory Agency.www.mhra.gov.uk [Free Full-text]
Moore, M. and Little, P. (2006) Humidified air inhalation for treating croup (Cochrane Review) [Withdrawn]. The Cochrane Library.Issue 3.John Wiley & Sons, Ltd.www.thecochranelibrary.com [Free Full-text]
Moore, M. and Little, P. (2007) Humidified air inhalation for treating croup: a systematic review and meta-analysis. Family Practice 24(4), 295-301. [Abstract] [Free Full-text]
NICE (2007) Feverish illness in children. Assessment and initial management in children younger than 5 years (NICE guideline). .Clinical guideline 47.National Institute for Health and Clinical Excellence.www.nice.org.uk [Free Full-text]
Russell, K.F., Liang, Y., O'Gorman, K. et al. (2011) Glucocorticoids for croup (Cochrane Review). .Issue 1.John Wiley & Sons, Ltd.www.thecochranelibrary.com [Free Full-text]
Scolnik, D., Coates, A.L., Stephens, D. et al. (2006) Controlled delivery of high vs low humidity vs mist therapy for croup in emergency departments: a randomized controlled trial. Journal of the American Medical Association 295(11), 1274-1280. [Abstract] [Free Full-text]
Sparrow, A. and Geelhoed, G. (2006) Prednisolone versus dexamethasone in croup: a randomised equivalence trial. Archives of Disease in Childhood 91(7), 580-583. [Abstract] [Free Full-text]
Sydney West Area Health Service (2004) Nurse practitioner clinical practice guidelines for the management of croup. ..NSW Health.www.health.nsw.gov.au [Free Full-text]
Vyas, J. (2007) Croup. New Zealand Family Physician 34(4), 266-269. [Free Full-text]
Wagener, J.S., Landau, L.I., Olinsky, A. and Phelan, P.D. (1986) Management of children hospitalized for laryngotracheobronchitis. Pediatric Pulmonology 2(3), 159-162. [Abstract]