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Akcan Yildiz L, Akca H, Kurt F, Hanalioglu D, Cetin M, Senel S, Karacan CD. Improving croup management at a pediatric emergency department. Postgrad Med 2024; 136:438-445. [PMID: 38804969 DOI: 10.1080/00325481.2024.2360889] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2024] [Accepted: 05/23/2024] [Indexed: 05/29/2024]
Abstract
OBJECTIVES Over-testing and over-treatment are common in children with croup at pediatric emergency departments (PED). The objective of the study was to improve care for children with croup. METHODS In this quality improvement (QI) initiative, all pediatric residents starting their rotation in the PED attended an informative presentation about croup and were provided reminders throughout their rotation. The primary outcome of this QI initiative was to reduce nebulized epinephrine (NE) use among children with mild croup by 50% over 7 months. The secondary outcome was to reduce X-rays by 50% over 7 months. Other outcomes included the administration of dexamethasone to all children with croup, reduction of antibiotics, laboratory tests, and revisits, and shortening the duration between physical examination to dexamethasone and NE treatments, and the length of stay (LOS) at the PED. RESULTS NE administration to patients with mild croup decreased from 80.2% to 36.3% (p < 0.001). The proportion of children with X-rays decreased from 37.4% to 17.1% (p < 0.001). There was a significant increase in dexamethasone administration, and significant decreases in laboratory blood tests, expanded viral PCR panel tests, and antibiotic prescription among all croup cases (p < 0.001). Revisit rates were not significantly different (p > 0.05). Time to dexamethasone and LOS shortened significantly (p < 0.001). CONCLUSION With this QI intervention, decreases in the rate of administration of NE to mild croup cases, antibiotic prescription, X-ray, laboratory blood and respiratory PCR panel tests in all croup cases were achieved without an increase in revisits. However, unnecessary NE, antibiotic, and X-ray rates are still high.
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Affiliation(s)
- Leman Akcan Yildiz
- Pediatric Emergency Clinic, Ankara Bilkent City Hospital, Ankara, Türkiye
| | - Halise Akca
- Pediatric Emergency Clinic, Ankara Bilkent City Hospital, Ankara, Türkiye
- Pediatric Emergency Department, Ankara Yildirim Beyazit University, Ankara, Türkiye
| | - Funda Kurt
- Pediatric Emergency Clinic, Ankara Bilkent City Hospital, Ankara, Türkiye
- Pediatric Emergency Department, University of Health Sciences, Ankara, Türkiye
| | - Damla Hanalioglu
- Pediatric Emergency Clinic, Ankara Bilkent City Hospital, Ankara, Türkiye
| | - Meltem Cetin
- Pediatric Emergency Clinic, Ankara Bilkent City Hospital, Ankara, Türkiye
| | - Saliha Senel
- Pediatric Emergency Clinic, Ankara Bilkent City Hospital, Ankara, Türkiye
- Pediatric Emergency Department, Ankara Yildirim Beyazit University, Ankara, Türkiye
| | - Can Demir Karacan
- Pediatric Emergency Clinic, Ankara Bilkent City Hospital, Ankara, Türkiye
- Pediatric Emergency Department, Ankara Yildirim Beyazit University, Ankara, Türkiye
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Kim BH, Ha EK, Yoo H, Lee S, Rha YH, Han MY, Kim JH. Trends in Incidence and Drug Prescriptions for Croup in Children Under 5 Years of Age: A 2002-2019 Population-Based Study. J Korean Med Sci 2024; 39:e95. [PMID: 38469967 PMCID: PMC10927388 DOI: 10.3346/jkms.2024.39.e95] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2023] [Accepted: 01/11/2024] [Indexed: 03/13/2024] Open
Abstract
BACKGROUND Tracking national croup trends can provide important insights for childhood health management. This study aimed to analyze the incidence and drug prescription trends in Korean children over a two-decade period. METHODS This population-based study encompassed 479,783 children aged < 5 years from 2002-2019, utilizing the National Health Insurance Service-National Sample Cohort. We identified participants with a primary croup diagnosis who were admitted to or visited the emergency room. Age-specific and age-adjusted incidence rates/10,000 person-years were calculated. We assessed using orthogonal polynomial contrasts and stratified by various factors (sex, age, residential area, economic status, comorbidities, and healthcare facility types). We observed changes in the use of five medications: inhaled steroids, systemic steroids, inhaled epinephrine, antibiotics, and short-acting bronchodilators. Generalized binomial logistic regression was used to analyze factors influencing prescription strategies. RESULTS In 2002, the croup-related visits were 16.1/10,000 person-years, increasing to 98.3 in 2019 (P for trend < 0.001). This trend persisted, regardless of age, sex, region, and economic status. Children with comorbid atopic dermatitis or asthma maintained consistent croup rates, while those without comorbidities increased. Treatment trends showed decreasing antibiotic (73-47%) and oxygen use (21.3-3.4%), with increasing nebulized epinephrine (9.3-41.5%) and multiple drug prescriptions (67.8-80.3%). Primary care centers exhibited a greater increase in prescription usage and hospitalization duration than did tertiary healthcare institutions. CONCLUSION Over the past two decades, croup incidence has risen, accompanied by increased epinephrine use and decreased antibiotic prescriptions. Longer hospitalization and higher medication use were mainly observed in primary care facilities.
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Affiliation(s)
- Bo Hee Kim
- Department of Pediatrics, Kyung Hee University Medical Center, Kyung Hee University College of Medicine, Seoul, Korea
| | - Eun Kyo Ha
- Department of Pediatrics, Hallym University Kangnam Sacred Heart Hospital, Hallym University College of Medicine, Seoul, Korea
| | - Hana Yoo
- Department of Orthopaedic Surgery, CHA Bundang Medical Center, CHA University School of Medicine, Seongnam, Korea
| | - Soonchul Lee
- Department of Orthopaedic Surgery, CHA Bundang Medical Center, CHA University School of Medicine, Seongnam, Korea
| | - Yeong Ho Rha
- Department of Pediatrics, Kyung Hee University Medical Center, Kyung Hee University College of Medicine, Seoul, Korea
| | - Man Yong Han
- Department of Pediatrics, CHA Bundang Medical Center, CHA University School of Medicine, Seongnam, Korea.
| | - Ju Hee Kim
- Department of Pediatrics, Kyung Hee University Medical Center, Kyung Hee University College of Medicine, Seoul, Korea.
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Lee EP, Mu CT, Yen CW, Hsia SH, Lin JJ, Chan OW, Chiu CC, Lai SH, Yang WC, Chen CY, Su YT, Wu HP. Predictors of disease severity and outcomes in pediatric patients with croup and COVID-19 in the pediatric emergency department. Am J Emerg Med 2023; 72:20-26. [PMID: 37453221 DOI: 10.1016/j.ajem.2023.06.050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2023] [Revised: 06/14/2023] [Accepted: 06/30/2023] [Indexed: 07/18/2023] Open
Abstract
BACKGROUND Croup caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is an emerging disease, and data on the risk factors associated with disease severity are still limited. The Westley croup score (WS) is widely used to assess croup severity. The current study aimed to analyze biomarkers associated with the WS and clinical outcomes in patients with croup and coronavirus disease 2019 in the pediatric emergency department (PED). POPULATION AND METHOD Patients diagnosed with croup caused by SARS-CoV-2 were admitted at two PEDs. Clinical data including age, WS, length of hospital stay, initial laboratory data, and treatment were analyzed. Clinical parameters were evaluated via multivariate logistic regression analysis. The best cutoff values for predicting croup severity and outcomes were identified using the receiver operating characteristic curve. RESULT In total, 250 patients were assessed. Moreover, 128 (51.2%) patients were discharged from the PED, and 122 (48.8%) were admitted to the hospital. Mild, moderate, and severe croup accounted for 63.6% (n = 159), 32% (n = 80), and 4.4% (n = 11) of all cases, respectively. A high mean age (years), neutrophil count (%), neutrophil-to-lymphocyte ratio (NLR), ALT (U/L), procalcitonin (ng/mL), and hemoglobin (g/dL) level, and length of hospital stay (days), and a low lymphocyte count (%) and blood pH were associated with croup severity and need for intensive care. Based on the multivariate logistic regression model, the NLR remained independent factors associated with croup severity and prognosis. Further, NLR was significantly correlated with WS. The area under the receiver operating characteristic curve of NLR for predicting a WS of ≥3 was 0.895 (0.842-0.948, p < 0.001), and that for predicting ICU admission was 0.795 (0.711-0.879, p < 0.001). The best cutoff values for a WS of ≥3 and ICU admission were 1.65 and 2.06, respectively. CONCLUSION NLR is correlated with WS and is a reliable, easy-to-use, and cheap biomarker for the early screening and prognosis of croup severity in the PED. A higher NLR may indicate severe croup and the need for further treatment. And the WS score remains reliable for estimating the severity of croup caused by SARS-CoV-2 and the risk of intensive care.
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Affiliation(s)
- En-Pei Lee
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Chang Gung Memorial Hospital at Linko, Kweishan, Taoyuan, Taiwan; College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Chun-Ting Mu
- College of Medicine, Chang Gung University, Taoyuan, Taiwan; Chang Gung Memorial Hospital, Chang Gung University, Taoyuan, Taiwan
| | - Chen-Wei Yen
- College of Medicine, Chang Gung University, Taoyuan, Taiwan; Division of Nephrology, Department of Pediatrics, Chang Gung Memorial Hospital, Chang Gung University, Taoyuan, Taiwan; Division of Pediatric General Medicine, Department of Pediatrics, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Shao-Hsuan Hsia
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Chang Gung Memorial Hospital at Linko, Kweishan, Taoyuan, Taiwan; College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Jainn-Jim Lin
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Chang Gung Memorial Hospital at Linko, Kweishan, Taoyuan, Taiwan; College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Oi-Wa Chan
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Chang Gung Memorial Hospital at Linko, Kweishan, Taoyuan, Taiwan; College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Chun-Che Chiu
- College of Medicine, Chang Gung University, Taoyuan, Taiwan; Department of Pediatrics, Tucheng Composite Municipal Hospital, New Taipei City, Taiwan
| | - Shen-Hao Lai
- College of Medicine, Chang Gung University, Taoyuan, Taiwan; Division of Pediatric Pulmonology, Department of Pediatrics, Chang Gung Memorial Hospital at Linkou, Taoyuan, Taiwan
| | - Wen-Chieh Yang
- Department of Pediatric Emergency, China Medical University Children's Hospital, China Medical University, Taichung City, Taiwan; Department of Medicine, College of Medicine, China Medical University, Taichung City, Taiwan
| | - Chun-Yu Chen
- Department of Pediatric Emergency, China Medical University Children's Hospital, China Medical University, Taichung City, Taiwan; Department of Medicine, College of Medicine, China Medical University, Taichung City, Taiwan
| | - Ya-Ting Su
- College of Medicine, Chang Gung University, Taoyuan, Taiwan; Division of Pediatric Endocrinology and Genetics, Department of Pediatrics, Chang Gung Memorial Hospital, Taipei, Taiwan
| | - Han-Ping Wu
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Chang Gung Memorial Hospital at Linko, Kweishan, Taoyuan, Taiwan; College of Medicine, Chang Gung University, Taoyuan, Taiwan; Department of Pediatrics, Chiayi Chang Gung Memorial Hospital, Chiayi, Taiwan.
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Croup associated with COVID-19: A case series. JEM REPORTS 2023; 2:100011. [PMID: 36865663 PMCID: PMC9899123 DOI: 10.1016/j.jemrpt.2023.100011] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/17/2022] [Revised: 12/10/2022] [Accepted: 01/19/2023] [Indexed: 02/07/2023]
Abstract
Background Croup encounters substantially decreased when the pandemic first began, specifically between March and September 2020, before croup cases dramatically spiked again with the Omicron variant. There is a dearth of information concerning children at risk for severe or refractory COVID-19-associated croup and their outcomes. Objective The objective of this case series was to describe the clinical characteristics and outcomes of croup associated with the Omicron variant in children, with a focus on cases refractory to treatment. Methods The case series includes children from birth to 18 years old who presented to a freestanding children's hospital emergency department in the Southeastern United States between December 1, 2021 and January 31, 2022 with a diagnosis of croup and a laboratory-confirmed diagnosis of COVID-19. We used descriptive statistics to summarize patient characteristics and outcomes. Results Of the total 81 patient encounters, 59 patients (72.8%) were discharged from the ED, with one patient requiring two revisits to the hospital. Nineteen patients (23.5%) were admitted to the hospital, and three of these patients represented to the hospital after discharge from the hospital. Three patients (3.7%) were admitted to the intensive care unit, none of whom represented after discharge. Conclusions This study reveals a wide age range of presentation as well as a relatively higher rate of admission and fewer coinfections compared to pre-pandemic croup. Reassuringly, the results also show a low postadmission intervention rate as well as a low revisit rate. We discuss four refractory cases to highlight nuances for management and disposition decisions.
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Walsh PS, Zhang Y, Lipshaw MJ. Variation in Emergency Department Use of Racemic Epinephrine and Associated Outcomes for Croup. Hosp Pediatr 2023; 13:167-173. [PMID: 36651069 DOI: 10.1542/hpeds.2022-006905] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
OBJECTIVES Racemic epinephrine (RE) is commonly administered for croup in the emergency department (ED). Our objectives were to examine variation in RE use between EDs, to determine whether ED variation in RE use is associated with hospital or patient factors, and to evaluate the associations between the rates of hospital-specific ED RE use and patient outcomes. METHODS We performed a retrospective cohort study using the Pediatric Heath Information System of children aged 3 months to 10 years with croup in the ED. We used mixed-effects regression to calculate risk-standardized proportions of patients receiving RE in each ED and to analyze the relationship between risk-standardized institutional RE use and individual patient odds of hospital admission, ICU admission, and ED revisits. RESULTS We analyzed 231 683 patient visits from 39 hospitals. ED administration of RE varied from 14% to 48% of visits (median, 24.5%; interquartile range, 20.0%-27.8%). A total of 8.6% of patients were hospitalized and 1% were admitted to the ICU. After standardizing for case mix and site effects, increasing ED use of RE per site was associated with increasing patient odds of hospital admission (odds ratio [OR], 1.39-95%; confidence interval [CI], 1.01-1.91), but not ICU admission (OR, 1.39; 95% CI, 0.99-1.97) or ED revisit (OR, 1.00; 95% CI, 0.92-1.09). CONCLUSIONS In this large, observational study, RE administration varied widely across EDs. Increased RE use by site was associated with increased odds of hospital admission for individual patients when controlling for patient factors. These results suggest further standardization of RE use in children with croup is warranted.
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Affiliation(s)
- Patrick S Walsh
- Section of Pediatric Emergency Medicine, Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Yin Zhang
- Divisions of Biostatistics and Epidemiology
| | - Matthew J Lipshaw
- Emergency Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio.,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
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Abstract
BACKGROUND Glucocorticoids are the mainstay for the treatment of croup. The existing evidence demonstrates that glucocorticoids are effective in the treatment of croup in children. However, updating the evidence on their clinical relevance in croup is imperative. This is an update to a review first published in 1999, and updated in 2004, 2011, and 2018. OBJECTIVES To investigate the effects and safety of glucocorticoids in the treatment of croup in children aged 18 years and below. SEARCH METHODS We searched the Cochrane Library, which includes the Cochrane Central Register of Controlled Trials (CENTRAL; 2022 Issue 9), Ovid MEDLINE Epub Ahead of Print, In-Process & Other Non-Indexed Citations and Ovid MEDLINE (1946 to 4 March 2022), Embase (Ovid) (1974 to 4 March 2022). We also searched the WHO ICTRP and ClinicalTrials.gov on 4 March 2022. SELECTION CRITERIA We included randomised controlled trials (RCTs) in children (aged 18 years and below) with croup. We assessed the effect of glucocorticoids compared to the following: placebo, any other pharmacologic agents, any other glucocorticoids, any combination of other glucocorticoids, given by different modes of administration, or given in different doses. The included studies must have assessed at least one of our primary outcomes (defined as the change in croup score or return visits, (re)admissions to the hospital or both) or secondary outcomes (defined as the length of stay in hospital or emergency departments, patient improvement, use of additional treatments, or adverse events). DATA COLLECTION AND ANALYSIS Review authors independently extracted data, with another review author verified. We entered the data into Review Manager 5 for meta-analysis. Two review authors independently assessed studies for risk of bias using the Cochrane risk of bias tool. Two review authors assessed the certainty of the evidence for the primary outcomes using the GRADE approach. MAIN RESULTS This updated review includes 45 RCTs with a total of 5888 children, an increase of two RCTs with 1323 children since the last update. We also identified one ongoing study and one study awaiting classification. We assessed most studies (98%) as at high or unclear risk of bias. Any glucocorticoid compared to placebo Compared to placebo, glucocorticoids may result in greater reductions in croup score after two hours (standardised mean difference (SMD) -0.65, 95% confidence interval (CI) -1.13 to -0.18; 7 RCTs, 426 children; low-certainty evidence); six hours (SMD -0.76, 95% CI -1.12 to -0.40; 11 RCTs, 959 children; low-certainty evidence); and 12 hours (SMD -1.03, 95% CI -1.53 to -0.53; 8 RCTs, 571 children; low-certainty evidence). The evidence for change in croup score after 24 hours is very uncertain (SMD -0.86, 95% CI -1.40 to -0.31; 8 RCTs, 351 children; very low-certainty evidence). One glucocorticoid compared to another glucocorticoid There was little to no difference between prednisolone and dexamethasone for reduction in croup score at two-hour post-baseline score (SMD 0.06, 95% CI -0.06 to 0.18; 1 RCT, 1231 children; high-certainty evidence). There was likely little to no difference between prednisolone and dexamethasone for reduction in croup score at six-hour post-baseline score (SMD 0.21, 95% CI -0.21 to 0.62; 1 RCT, 99 children; moderate-certainty evidence). However, dexamethasone probably reduced the return visits or (re)admissions for croup by almost half (risk ratio (RR) 0.55, 95% CI 0.28 to 1.11; 4 RCTs, 1537 children; moderate-certainty evidence), and showed a 28% reduction in the use of supplemental glucocorticoids as an additional treatment (RR 0.72, 95% CI 0.53 to 0.97; 2 RCTs, 926 children). Dexamethasone given in different doses Compared to 0.15 mg/kg, 0.60 mg/kg dexamethasone probably reduced the severity of croup as assessed by the croup scoring scale at 24-hour postbaseline score (SMD 0.63, 95% CI 0.16 to 1.10; 1 RCT, 72 children; moderate-certainty evidence); however, this was not the case at two hours (SMD -0.27, 95% CI -0.76 to 0.22; 2 RCTs, 861 children; high-certainty evidence). There was probably no reduction at six hours (SMD -0.45, 95% CI -1.26 to 0.35; 3 RCTs, 178 children; moderate-certainty evidence), and the evidence at 12 hours is very uncertain (SMD -0.60, 95% CI -4.39 to 3.19; 2 RCTs, 113 children; very low-certainty evidence). There was little to no difference between doses of dexamethasone in return visits or (re)admissions of children or both (RR 0.91, 95% CI 0.71 to 1.17; 3 RCTs, 949 children; high-certainty evidence) or length of stay in the hospital or emergency department (mean difference 0.12, 95% CI -0.32 to 0.56; 2 RCTs, 892 children). The need for additional treatments, such as epinephrine (RR 0.78, 95% CI 0.34 to 1.75; 2 RCTs, 885 children); intubation (risk difference 0.00, 95% CI -0.00 to 0.00; 2 RCTs, 861 children); or use of supplemental glucocorticoids (RR 0.77, 95% CI 0.51 to 1.15; 2 RCTs, 617 children), also did not differ between doses of dexamethasone. There were moderate to high levels of heterogeneity in the analyses for most comparisons. Adverse events were observed for some of the comparisons reported in the review. AUTHORS' CONCLUSIONS The evidence that glucocorticoids reduce symptoms of croup at two hours, shorten hospital stays, and reduce the rate of return visits or (re)admissions has not changed in this update. A smaller dose of 0.15 mg/kg of dexamethasone may be as effective as the standard dose of 0.60 mg/kg. More RCTs are needed to strengthen the evidence for effectiveness of low-dose dexamethasone at 0.15 mg/kg to treat croup.
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Affiliation(s)
- Alex Aregbesola
- Department of Pediatrics and Child Health, Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Canada
- Children's Hospital Research Institute of Manitoba, Winnipeg, Canada
| | - Clara M Tam
- Children's Hospital Research Institute of Manitoba, Winnipeg, Canada
| | - Asha Kothari
- Children's Hospital Research Institute of Manitoba, Winnipeg, Canada
| | - Me-Linh Le
- Neil John Maclean Health Sciences Library, University of Manitoba, Winnipeg, Canada
| | - Mirna Ragheb
- Children's Hospital Research Institute of Manitoba, Winnipeg, Canada
| | - Terry P Klassen
- Department of Pediatrics and Child Health, Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Canada
- Children's Hospital Research Institute of Manitoba, Winnipeg, Canada
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Walsh PS, Lipshaw MJ. Diurnal Variation in Frequency and Severity of Croup in the Emergency Department. Hosp Pediatr 2022; 12:e2022006682. [PMID: 36130916 DOI: 10.1542/hpeds.2022-006682] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
BACKGROUND Emergency department (ED) presentation for croup is thought to occur more often at night, but evidence for its diurnal variation is sparse. Our objectives were to describe the diurnal patterns of ED presentation in children with croup and to determine whether time of arrival associated with severe clinical outcomes. METHODS We conducted a retrospective cohort study using the Pediatric Health Information System. We included children 3 months to 11 years of age with an ED encounter for croup from 2016 through 2020. We quantified ED encounters by arrival hour and used generalized linear mixed-effects models to determine association between arrival time and racemic epinephrine use, hospitalization, intensive care unit (ICU) admission, and revisits. RESULTS There was considerable diurnal variation in ED visits for croup. A total of 126 186 children (60.1%) presented to the ED at night (between 8 pm and 8 am), and 83 763 children presented during the day (39.9%). Peak arrival time was 12:00 am (14 189 encounters) and the nadir was at 2:00 pm (5231 encounters). Children presenting during overnight hours had increased odds of the use of racemic epinephrine (odds ratio [OR] 1.33; 95% confidence interval [95% CI], 1.30-1.36), but reduced odds of hospitalization (OR 0.76; 95% CI, 0.73-0.78), ICU admission (OR 0.61; 95% CI, 0.58-0.68), and 3 day ED revisits (OR 0.86; 95% CI, 0.83-0.90). CONCLUSIONS Children with croup present to the ED more commonly at night. Children presenting to the ED with croup at night have greater odds of being treated with racemic epinephrine, but reduced odds of hospitalization, ICU admission, and return visits.
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Affiliation(s)
- Patrick S Walsh
- Division of Emergency Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Matthew J Lipshaw
- Division of Emergency Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
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Pierantoni L, Stera G, Andreozzi L, Pellegrino F, Dondi A, Fabi M, Corsini I, Ghizzi C, Lanari M. Multicentre study revealed significant gaps between evidence-based recommendations for using corticosteroids for croup and clinical practice. Acta Paediatr 2022; 111:2010-2016. [PMID: 35751481 DOI: 10.1111/apa.16468] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2022] [Revised: 06/22/2022] [Accepted: 06/23/2022] [Indexed: 11/26/2022]
Abstract
AIM Adherence to croup management recommendations has been poorly investigated. This study aimed to describe the treatment patterns in two paediatric emergency departments and analyse the adherence to recommendations. METHODS We conducted a retrospective chart review of children diagnosed with croup in two Italian pediatric emergency departments in 2017. Data on clinical presentation, corticosteroid administration and home therapy were collected. Length of stay, hospitalisation and re-access rates were compared among different corticosteroid treatment groups. RESULTS We enrolled 632 patients (61.1% males) with a mean age of 42.8±55.1 months. Corticosteroids were administered to 403 (63.8%) children in the emergency departments. Dexamethasone was administered to 1 (0.4%) patient. Inhaled and oral corticosteroids were given to 342 (54.1%) and 226 (35.8%) patients, respectively. Home therapy was prescribed for 603 (95.4%) patients, either with inhaled (86.2%) and/or oral (43.8%) corticosteroids. The re-access rate was 2.8%. The actual pharmaceutical costs were an estimated 10 times higher than they would have been if the recommendations had been followed. CONCLUSION A significant gap between the evidence and clinical practice for croup treatment was observed. Improving adherence to the recommendations could lead to clinical and economic benefits.
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Affiliation(s)
- Luca Pierantoni
- Pediatric Emergency Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Italy
| | - Giacomo Stera
- Specialty School of Paediatrics, Alma Mater Studiorum, University of Bologna, Italy
| | - Laura Andreozzi
- Pediatric Emergency Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Italy
| | - Francesco Pellegrino
- Pediatric Emergency Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Italy
| | - Arianna Dondi
- Pediatric Emergency Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Italy
| | - Marianna Fabi
- Pediatric Emergency Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Italy
| | - Ilaria Corsini
- Pediatric Emergency Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Italy
| | | | - Marcello Lanari
- Pediatric Emergency Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Italy
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Baša M, Sovtić A. Treatment of the most common respiratory infections in children. ARHIV ZA FARMACIJU 2022. [DOI: 10.5937/arhfarm72-37857] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022] Open
Abstract
Acute respiratory infections are the most common group of infective diseases in the pediatric population. Although the improvement of health care and vaccination program has led to a significant reduction in the incidence of certain respiratory infections, the combination of a high prevalence in vulnerable pediatric categories and uncritical prescription of antibiotics, due to the inability to adequately distinguish between viruses and bacterial etiology, still represents a significant challenge for the public health system. In order to promote rational antibiotic therapy with an overall improvement of both diagnostic and therapeutic principles, acute respiratory diseases have been the subject of consideration in numerous publications and national guidelines. Nonspecific clinical manifestations with pathogen heterogeneity and both anatomical and physiological characteristics of the child's respiratory system during growth and development have created the need for individualized therapy. Since the guidelines emphasize the undoubtful and crucial benefits of symptomatic therapy (e.g. analgesics in acute otitis media, supplemental oxygen in lower respiratory tract infections with hypoxemia), the use of antibiotics and corticosteroids is indicated in selected cases with a severe clinical picture. The choice of antibiotic depends on the clinical condition, presumed causative agent, and local epidemiologic circumstances. Respiratory support (oxygen therapy and/or artificial ventilation) is reserved for inpatient treatment of cases with a particularly severe clinical picture and associated complications.
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Tyler A, Bryan MA, Zhou C, Mangione-Smith R, Williams D, Johnson DP, Kenyon CC, Rasooly I, Neubauer HC, Wilson KM. Variation in Dexamethasone Dosing and Use Outcomes for Inpatient Croup. Hosp Pediatr 2022; 12:22-29. [PMID: 34846064 PMCID: PMC8882347 DOI: 10.1542/hpeds.2021-005854] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
OBJECTIVES Evaluate the association between dexamethasone dosing and outcomes for children hospitalized with croup. METHODS This study was nested within a multisite prospective cohort study of children aged 6 months to 6 years admitted to 1 of 5 US children's hospitals between July 2014 and June /2016. Multivariable linear and logistic mixed-effects regression models were used to examine the association between the number of dexamethasone doses (1 vs >1) and outcomes (length of stay [LOS], cost, and 30-day same-cause reuse). All multivariable analyses included a site-specific random effect to account for clustering within hospital and were adjusted for age, sex, race and ethnicity, presenting severity, medical complexity, insurance, caregiver education, and hospital. In cost analyses, we controlled for LOS. RESULTS Among 234 children hospitalized with croup, patient characteristics did not differ by number of doses. The proportion receiving >1 dose varied by hospital (range 27.9%-57.1%). In adjusted analyses, >1 dose was not associated with same-cause reuse (odds ratio 0.87 [95% confidence interval (CI): 0.26 to 2.95]) but was associated with 45% longer LOS (relative risk = 1.45 [95% CI: 1.30 to 1.62]). When we controlled for LOS, >1 dose was not associated with differential cost ($-31.2 [95% CI $-424.4 to $362.0]). Eighty-two (35%) children received dexamethasone before presentation. CONCLUSIONS We found significant interhospital variation in dexamethasone dosing and LOS. When we controlled for severity on presentation, >1 dexamethasone dose was associated with longer LOS but not reuse. Although incomplete adjustment for severity is one possible explanation, some providers may routinely keep children hospitalized to administer multiple dexamethasone doses.
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Affiliation(s)
- Amy Tyler
- Section of Hospital Medicine, Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO and Adult and Child Consortium for Health Outcomes Research and Delivery Science (ACCORDS)
| | - Mersine A. Bryan
- Department of Pediatrics, University of Washington, Seattle, WA,Seattle Children’s Research Institute, Seattle, WA
| | - Chuan Zhou
- Department of Pediatrics, University of Washington, Seattle, WA,Seattle Children’s Research Institute, Seattle, WA
| | | | - Derek Williams
- Division of Hospital Medicine, Monroe Carell Jr. Children’s Hospital at Vanderbilt, Department of Pediatrics, Vanderbilt University School of Medicine, Nashville, TN
| | - David P. Johnson
- Division of Hospital Medicine, Monroe Carell Jr. Children’s Hospital at Vanderbilt, Department of Pediatrics, Vanderbilt University School of Medicine, Nashville, TN
| | - Chén C Kenyon
- Center for Pediatric Clinical Effectiveness, The Children’s Hospital of Philadelphia; Department of Pediatrics, University of Pennsylvania School of Medicine, Philadelphia, PA
| | - Irit Rasooly
- Center for Pediatric Clinical Effectiveness, The Children’s Hospital of Philadelphia; Department of Pediatrics, University of Pennsylvania School of Medicine, Philadelphia, PA
| | - Hannah C. Neubauer
- Section of Pediatric Hospital Medicine, Department of Pediatrics, Baylor College of Medicine, Houston, TX
| | - Karen M. Wilson
- Kravis Children’s Hospital at the Icahn School of Medicine at Mount Sinai, New York City, NY
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11
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Vigneault LP, Diendere E, Sohier-Poirier C, Abi Hanna M, Poirier A, St-Onge M. Acute health care among Indigenous patients in Canada: a scoping review. Int J Circumpolar Health 2021; 80:1946324. [PMID: 34320910 PMCID: PMC8330756 DOI: 10.1080/22423982.2021.1946324] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2021] [Revised: 06/14/2021] [Accepted: 06/17/2021] [Indexed: 11/25/2022] Open
Abstract
A recent report by the Chief Public Health Officer of Canada demonstrates the inferior health status of Indigenous Peoples in Canada when compared to non-Indigenous populations. This scoping review maps out the available literature concerning acute health care for Indigenous Peoples in Canada in order to better understand the health care issues they face. All existing articles concerning health care provided to Indigenous Peoples in Canada in acute settings were included in this review. The targeted studied outcomes were access to care, health care satisfaction, hospital visit rates, mortality, quality of care, length of stay and cost per hospitalisation. 114 articles were identified. The most studied outcomes were hospitalisation rates (58.8%), length of stay (28.0%), mortality (25.4%) and quality of care (24.6%) Frequently studied topics included pulmonary disease, injuries, cardiovascular disease and mental illness. Indigenous Peoples presented lower levels of satisfaction and access to care although they tend to be over-represented in hospitalisation rates for acute care. Greater inclusion of Indigenous Peoples in the health care system and in the training of health care providers is necessary to ensure a better quality of care that is culturally safe for Indigenous Peoples.
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Affiliation(s)
| | - Ella Diendere
- Centre de recherche sur les soins et les services de première ligne de l’Université Laval (CERSSPL-UL), Quebec, Canada
| | | | - Margo Abi Hanna
- Faculty of Medicine and Health Sciences, McGill University, Montreal, Canada
| | - Annie Poirier
- Département de médecine familiale et de médecine d'urgence, Université Laval, Quebec, Canada
| | - Maude St-Onge
- Département de médecine familiale et de médecine d'urgence, Université Laval, Quebec, Canada
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12
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Elliott SA, Wright KS, Scott SD, Hartling L. Perspectives from French and Filipino parents on the adaptation of child health knowledge translation tools: a qualitative exploration (Preprint). JMIR Form Res 2021; 6:e33156. [PMID: 35333185 PMCID: PMC8994152 DOI: 10.2196/33156] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2021] [Revised: 01/31/2022] [Accepted: 02/03/2022] [Indexed: 01/23/2023] Open
Abstract
Background A number of evidence-based knowledge translation (KT) tools for parents of children with acute health conditions have been developed. These tools were created and tested with parental input and disseminated to groups proficient in English. Therefore, it is unclear whether they are useful for populations that are more diverse. To enhance the reach of our current and future KT tools, language translation and cultural adaptations may promote relevance for previously underserved knowledge users. Objective This study aims to explore and understand considerations for the cultural and linguistic adaptation of a KT tool in French and Filipino communities. Methods A KT tool (whiteboard animation video) describing the signs and symptoms of croup was originally developed in English to provide parents with evidence-based information couched within a narrative reflecting parents’ experiences with the condition. This KT tool was adapted (linguistics and imagery) for French- and Tagalog-speaking parents and caregivers through feedback from key stakeholders. The videos were presented to the respective language speakers for usability testing and discussion. Participants were asked to view the KT tool, complete a usability survey, and participate in semistructured interviews. Audio recordings from the interviews were transcribed verbatim, translated into English, and analyzed for relevant themes by using thematic analysis. Results French- (n=13) and Tagalog-speaking (n=13) parents completed the usability survey and were interviewed. Although analyzed separately, both data sets produced similar findings, with key themes relating to understanding, relatability, and accessibility. Both the French and Tagalog groups reported that the video and other KT tools were useful in their adapted forms. Participants in both groups cautioned against using verbatim vocabulary and suggested that cultural competency and understanding of health languages were essential for high-quality translations. Parents also discussed their preference for videos with diverse visual representations of families, home environments, and health care workers, as such videos represent their communities more broadly. Conclusions French and Filipino parents appreciated having KT tools in their first language; however, they were also supportive of the use of English KT products. Their suggestions for improving the relatability and communication of health messages are important considerations for the development and adaptation of future KT products. Understanding the needs of the intended end users is a crucial first step in producing relevant tools for health evidence dissemination.
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Affiliation(s)
- Sarah A Elliott
- Alberta Research Centre for Health Evidence, Department of Pediatrics, University of Alberta, Edmonton, AB, Canada
- Cochrane Child Health, Department of Pediatrics, University of Alberta, Edmonton, AB, Canada
| | - Kelsey S Wright
- Alberta Research Centre for Health Evidence, Department of Pediatrics, University of Alberta, Edmonton, AB, Canada
| | - Shannon D Scott
- Faculty of Nursing, University of Alberta, Edmonton, AB, Canada
| | - Lisa Hartling
- Alberta Research Centre for Health Evidence, Department of Pediatrics, University of Alberta, Edmonton, AB, Canada
- Cochrane Child Health, Department of Pediatrics, University of Alberta, Edmonton, AB, Canada
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13
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Pound CM, Knight BD, Webster R, Benchimol EI, Radhakrishnan D. Predictors of Hospitalization for Children With Croup, a Population-Based Cohort Study. Hosp Pediatr 2020; 10:1068-1077. [PMID: 33203748 DOI: 10.1542/hpeds.2020-001362] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
OBJECTIVES We sought to determine predictors of hospitalization for children presenting with croup to emergency departments (EDs), as well as predictors of repeat ED presentation and of hospital readmissions within 18 months of index admission. We also aimed to develop a practical tool to predict hospitalization risk upon ED presentation. METHODS Multiple deterministically linked health administrative data sets from Ontario, Canada, were used to conduct this population-based cohort study between April 1, 2006 and March 31, 2017. Children born between April 1, 2006, and March 31, 2011, were eligible if they had 1 ED visit with a croup diagnosis. Multivariable logistic regression was used to determine factors associated with hospitalization, subsequent ED visits, and subsequent croup hospitalizations. A multivariable prediction tool and associated scoring system were created to predict hospitalization risk within 7 days of ED presentation. RESULTS Overall, 1811 (3.3%) of the 54 981 eligible children who presented to an Ontario ED were hospitalized. Significant hospitalization predictors included age, sex, Canadian Triage and Acuity Scale score, gestational age at birth, and newborn distress. Younger patients and boys were more likely to revisit the ED for croup. Our multivariable prediction tool could forecast hospitalization up to a 32% probability for a given patient. CONCLUSIONS This study is the first population-based study in which predictors of hospitalization for croup based on demographic and historical factors are identified. Our prediction tool emphasized the importance of symptom severity on ED presentation but will require refinement before clinical implementation.
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Affiliation(s)
- Catherine M Pound
- Children's Hospital of Eastern Ontario Research Institute, Ottawa, Canada;
- Divisions of Pediatrics
- Department of Pediatrics and
| | - Braden D Knight
- ICES uOttawa, Ottawa, Canada
- Clinical Research Unit
- Ontario Child Health Support Unit, Ontario, Canada; and
- Ottawa Hospital Research Institute, Ottawa, Canada
| | - Richard Webster
- Clinical Research Unit
- Ontario Child Health Support Unit, Ontario, Canada; and
| | - Eric I Benchimol
- Children's Hospital of Eastern Ontario Research Institute, Ottawa, Canada
- Department of Pediatrics and
- ICES uOttawa, Ottawa, Canada
- Gastroenterology, Hepatology and Nutrition, Children's Hospital of Eastern Ontario, Ottawa, Canada
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Canada
| | - Dhenuka Radhakrishnan
- Children's Hospital of Eastern Ontario Research Institute, Ottawa, Canada
- Department of Pediatrics and
- ICES uOttawa, Ottawa, Canada
- Respirology, and
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Abstract
OBJECTIVES Croup occasionally requires medical intervention for respiratory distress. Mainstays of treatment are corticosteroids and nebulized epinephrine. Diagnosis and assessment of severity remain clinical. Safety of discharge from an emergency department (ED) after treatment with corticosteroids and 1 nebulized epinephrine has been established. No evidence exists regarding risk associated with discharge after multidose nebulized epinephrine. Many patients requiring multidose nebulized epinephrine are reflexively admitted. The purpose of this study was to provide a descriptive analysis of the current management of croup, specifically patients requiring multidose nebulized epinephrine. METHODS The Pediatric Health Information System was used to extract information on patients diagnosed with croup age 0 to 11 years, evaluated in pediatric EDs from 2004 to 2014, who received corticosteroids and at least 1 nebulized epinephrine. We retrospectively assessed patients requiring multidose nebulized epinephrine, evaluating risk of return for additional care associated with discharges and reviewing admissions for markers of disease severity. RESULTS A total of 95,403 patients were identified. Those requiring corticosteroids and multidose nebulized epinephrine (N = 8084) were less likely to return for further care if discharged from the ED (5.4% return single dose, 0.8% return multidose: P < 0.0001) and were admitted at a higher rate (10.7% admission single dose, 70.5% admission multidose: P < 0.0001). Of those admitted, only 31.7% received more than 2 treatments. CONCLUSIONS Patients requiring single-dose nebulized epinephrine are managed differently than those requiring multidose nebulized epinephrine. There is likely a role for multidose nebulized epinephrine in the outpatient management of croup. A prospective study is needed.
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Chiang E, Afandi O, Lee SH, Suresh S, Pitetti RD, Ramgopal S. Inpatient use of racemic epinephrine for children admitted with croup. World J Pediatr 2019; 15:586-594. [PMID: 31342466 DOI: 10.1007/s12519-019-00291-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2019] [Accepted: 07/08/2019] [Indexed: 12/01/2022]
Abstract
BACKGROUND Pediatric patients with croup are frequently admitted if they require two doses of racemic epinephrine (RE) in the emergency department (ED). We aimed to identify factors associated with the need for additional therapy (> 2 RE doses) among pediatric patients with croup. METHODS We performed a single-center retrospective study of consecutive patients admitted from the ED with a diagnosis of croup between January 1, 2011 and December 31, 2015. Primary outcome was need for > 2 doses of RE. Secondary outcomes included time to third RE and 72-hour return visits. We performed logistic regression to identify factors associated with use of > 2 RE doses during hospitalization, and survival analysis to identify time to dosing of 3rd RE from 2nd RE. RESULTS Of 353 included admissions [250 (70.8%) males, median age 1.48, interquartile range 0.97-2.51 years], 106/353 (30.0%) required > 2 RE. In univariate logistic regression, only recent use of steroids within 1 day prior to presentation (4.18, 1.48-11.83; P = 0.007) was associated with need for > 2 RE. Survival from third RE was 0.74 (95% CI 0.69-0.78), which was similar to the survival at 12 hours (0.70, 95% CI 0.65-0.75). Return visits occurred in 19 (5.4%) patients, of whom 12/19 (63.2%) were given RE. CONCLUSIONS Patients hospitalized for croup with recent use of steroids prior to ED presentation have a greater need for > 2 RE during hospitalization. The majority who require inpatient RE will do so within 8-12 hours. These data provide information for risk stratification and duration of monitoring for patients hospitalized with croup.
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Affiliation(s)
- Elaine Chiang
- Division of Pediatric Emergency Medicine, Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.,UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA, USA
| | - Omar Afandi
- Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.,UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA, USA
| | - Sang Hoon Lee
- Department of Pediatrics, University of Cincinnati, College of Medicine, Cincinnati, OH, USA.,Division of Emergency Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Srinivasan Suresh
- Division of Pediatric Emergency Medicine, Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.,Division of Health Informatics, Department of Pediatrics, University of Pittsburgh School of Medicine, Children's Hospital of Pittsburgh, Pittsburgh, PA, USA.,UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA, USA
| | - Raymond D Pitetti
- Division of Pediatric Emergency Medicine, Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.,UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA, USA
| | - Sriram Ramgopal
- Division of Pediatric Emergency Medicine, Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA. .,UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA, USA.
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16
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Hanna J, Brauer PR, Morse E, Berson E, Mehra S. Epidemiological analysis of croup in the emergency department using two national datasets. Int J Pediatr Otorhinolaryngol 2019; 126:109641. [PMID: 31442871 DOI: 10.1016/j.ijporl.2019.109641] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2019] [Revised: 07/11/2019] [Accepted: 08/09/2019] [Indexed: 11/19/2022]
Abstract
OBJECTIVES To characterize cases of croup presenting to emergency departments (EDs) nationwide, analyze trends, and determine readmission rates. METHODS Retrospective review of the Nationwide Emergency Department Sample (2007-2014) and the National Hospital Ambulatory Medical Care Survey (2008-2015). RESULTS Both databases provided similar descriptive statistics. Annual mean of 352,388 (weighted) cases in the National Emergency Department Sample (1.35% of ED cases). Average age and male:female ratio 2.50 years and 1.95:1, respectively. Peak incidence was in autumn (October = 13.7%) with troughs in the summer (July = 3.7%). 21.3% received nebulizers, <1% laryngoscopic or airway procedures, 75.1% steroids, and 13.3% antibiotics. Of the patients receiving antibiotics, 16.0% had isolated croup. 3.0% of cases were admitted to the hospital. No trend was identified in the incidence of croup, mean age, or antibiotic and steroid usage. Hospital admission rates decreased (4.0%-2.3%) and nebulizer usage increased (14.6%-27.5%; p < 0.05). 5% of patients represented repeat admissions (were seen within 72 h prior). CONCLUSIONS Croup imposes a significant burden on the ED. Although hospital admissions decreased, annual incidence in the ED remained stable. The majority of cases are in males less than three years old, and 5.0% of patients represented readmissions. Only three-quarters received glucocorticoids despite the proven benefits, including reducing readmission rates. Antibiotic usage was high, with a large number representing potential cases of inappropriate antibiotic use.
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Affiliation(s)
- Jonathan Hanna
- Department of Surgery, Section of Otolaryngology, Yale University School of Medicine, New Haven, CT, USA
| | - Philip R Brauer
- Department of Surgery, Section of Otolaryngology, Yale University School of Medicine, New Haven, CT, USA
| | - Elliot Morse
- Department of Surgery, Section of Otolaryngology, Yale University School of Medicine, New Haven, CT, USA
| | - Elisa Berson
- Department of Surgery, Section of Otolaryngology, Yale University School of Medicine, New Haven, CT, USA
| | - Saral Mehra
- Department of Surgery, Section of Otolaryngology, Yale University School of Medicine, New Haven, CT, USA; Department of Surgery, Section of Otolaryngology, Yale University School of Medicine, Yale-New Haven Hospital, Yale Cancer Center, New Haven, CT, USA.
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Feleszko W, Marengo R, Vieira AS, Ratajczak K, Mayorga Butrón JL. Immunity-targeted approaches to the management of chronic and recurrent upper respiratory tract disorders in children. Clin Otolaryngol 2019; 44:502-510. [PMID: 30920131 PMCID: PMC6850198 DOI: 10.1111/coa.13335] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2017] [Revised: 03/07/2019] [Accepted: 03/24/2019] [Indexed: 02/06/2023]
Abstract
Background Upper respiratory tract infections (URTIs), including rhinitis, nasopharyngitis, tonsillitis and otitis media (OM), comprise of 88% of total respiratory infections, especially in children. Therefore effective prevention and treatment of RTIs remain a high priority worldwide. Preclinical and clinical data highlight the rationale for the use and effectiveness of immunity‐targeted approaches, including targeted immunisations and non‐specific immunomodulation in the prevention and management of recurrent upper RTIs. Objective of review The idea of this review was to summarise the current evidence and address key questions concerning the use of conservative and immunity‐targeted approaches to recurrent and chronic URTIs, with a focus on the paediatric population. Search strategy/Evaluation method Literature searches were conducted in March 2017 and updated in September 2017 using: Academic Search Complete; CENTRAL; Health Source: Nursing/Academic Edition; MEDLINE; clinicaltrials.gov; and Cochrane databases. In total, 84 articles were retrieved and reviewed. Two independent researchers focused on primary and secondary endpoints in systematic reviews, meta‐analyses and randomised, controlled trials, using immunity‐directed strategies as the control group or within a subpopulation of larger studies. Existing guidelines and interventional/observational studies on novel applications were also included. Results Children are particularly susceptible to RTIs due to the relative immaturity of their immune systems, as well as other potential predisposing factors such as day care attendance and/or toxic environmental factors (eg increased pathogenic microbial exposure and air pollutants). Recurrent URTIs can affect otherwise healthy children, leading to clinical sequelae and complications, including the development of chronic conditions or the need for surgery. Available pre‐clinical and clinical data highlight the rationale for the use and effectiveness of immunity‐targeted approaches, including targeted immunisations (flu and pneumococcal vaccines) and non‐specific immunomodulation (bacterial lysates), in the prevention and management of recurrent croup, tonsillitis, otitis media, recurrent acute rhinosinusitis and chronic rhinosinusitis. Conclusions In this review, we summarise the current evidence and provide data demonstrating that some immunity‐targeted strategies, including vaccination and immunomodulation, have proved effective in the treatment and prevention of recurrent and chronic URTIs in children.
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Affiliation(s)
- Wojciech Feleszko
- Department of Paediatric Respiratory Diseases and Allergy, The Medical University of Warsaw, Warsaw, Poland
| | - Ricardo Marengo
- Department of Otorhinolaryngology and Audiology, CEMIC Institute, Buenos Aires, Argentina
| | | | - Karol Ratajczak
- Department of Paediatric Respiratory Diseases and Allergy, The Medical University of Warsaw, Warsaw, Poland
| | - José Luis Mayorga Butrón
- Department of Otorhinolaryngology, National Institute of Pediatrics, Cuicuilco, Mexico.,Master of Science Program, Postgraduate Unit, Faculty of Medicine, National University of Mexico, Cuicuilco, Mexico
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18
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Simmonds JC, Tuomi A, Groblewski JC. High rates of subglottic stenosis seen in African-American children admitted with severe croup to hospitals in the United States between 2003 and 2013. Respir Med 2018; 143:56-60. [DOI: 10.1016/j.rmed.2018.08.015] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2018] [Revised: 08/27/2018] [Accepted: 08/28/2018] [Indexed: 12/14/2022]
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Gates A, Gates M, Vandermeer B, Johnson C, Hartling L, Johnson DW, Klassen TP. Glucocorticoids for croup in children. Cochrane Database Syst Rev 2018; 8:CD001955. [PMID: 30133690 PMCID: PMC6513469 DOI: 10.1002/14651858.cd001955.pub4] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
BACKGROUND Glucocorticoids are commonly used for croup in children. This is an update of a Cochrane Review published in 1999 and previously updated in 2004 and 2011. OBJECTIVES To examine the effects of glucocorticoids for the treatment of croup in children aged 0 to 18 years. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (the Cochrane Library, Issue 2, 2018), which includes the Cochrane Acute Respiratory Infections Group's Specialised Register, Ovid MEDLINE Epub Ahead of Print, In-Process & Other Non-Indexed Citations and Ovid MEDLINE (1946 to 3 April 2018), and Embase (Ovid) (1996 to 3 April 2018, week 14), and the trials registers ClinicalTrials.gov (3 April 2018) and the World Health Organization International Clinical Trials Registry Platform (ICTRP, 3 April 2018). We scanned the reference lists of relevant systematic reviews and of the included studies. SELECTION CRITERIA We included randomised controlled trials (RCTs) that investigated children aged 0 to 18 years with croup and measured the effects of glucocorticoids, alone or in combination, compared to placebo or another pharmacologic treatment. The studies needed to report at least one of our primary or secondary outcomes: change in croup score; return visits, (re)admissions or both; length of stay; patient improvement; use of additional treatments; and adverse events. DATA COLLECTION AND ANALYSIS One author extracted data from each study and another verified the extraction. We entered the data into Review Manager 5 for meta-analysis. Two review authors independently assessed risk of bias for each study using the Cochrane 'Risk of bias' tool and the certainty of the body of evidence for the primary outcomes using the GRADE approach. MAIN RESULTS We added five new RCTs with 330 children. This review now includes 43 RCTs with a total of 4565 children. We assessed most (98%) studies as at high or unclear risk of bias. Compared to placebo, glucocorticoids improved symptoms of croup at two hours (standardised mean difference (SMD) -0.65, 95% confidence interval (CI) -1.13 to -0.18; 7 RCTs; 426 children; moderate-certainty evidence), and the effect lasted for at least 24 hours (SMD -0.86, 95% CI -1.40 to -0.31; 8 RCTs; 351 children; low-certainty evidence). Compared to placebo, glucocorticoids reduced the rate of return visits or (re)admissions or both (risk ratio 0.52, 95% CI 0.36 to 0.75; 10 RCTs; 1679 children; moderate-certainty evidence). Glucocorticoid treatment reduced the length of stay in hospital by about 15 hours (mean difference -14.90, 95% CI -23.58 to -6.22; 8 RCTs; 476 children). Serious adverse events were infrequent. Publication bias was not evident. Uncertainty remains with regard to the optimal type, dose, and mode of administration of glucocorticoids for reducing croup symptoms in children. AUTHORS' CONCLUSIONS Glucocorticoids reduced symptoms of croup at two hours, shortened hospital stays, and reduced the rate of return visits to care. Our conclusions have changed, as the previous version of this review reported that glucocorticoids reduced symptoms of croup within six hours.
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Affiliation(s)
- Allison Gates
- University of AlbertaDepartment of Pediatrics and the Alberta Research Centre for Health EvidenceEdmontonAlbertaCanadaT6G 1C9
| | - Michelle Gates
- University of AlbertaDepartment of Pediatrics and the Alberta Research Centre for Health EvidenceEdmontonAlbertaCanadaT6G 1C9
| | - Ben Vandermeer
- University of AlbertaDepartment of Pediatrics and the Alberta Research Centre for Health EvidenceEdmontonAlbertaCanadaT6G 1C9
| | - Cydney Johnson
- University of AlbertaDepartment of Pediatrics and the Alberta Research Centre for Health EvidenceEdmontonAlbertaCanadaT6G 1C9
| | - Lisa Hartling
- University of AlbertaDepartment of Pediatrics and the Alberta Research Centre for Health EvidenceEdmontonAlbertaCanadaT6G 1C9
| | - David W Johnson
- Faculty of Medicine, University of Calgary, Alberta Children's HospitalDepartment of Pediatrics2888 Shaganappi Trail NWCalgaryABCanadaT3B 6A8
| | - Terry P Klassen
- Manitoba Institute of Child Health513‐715 McDermot AvenueWinnipegMBCanadaR3E 3P4
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Elliott AC, Williamson GR. A Systematic Review and Comprehensive Critical Analysis Examining the Use of Prednisolone for the Treatment of Mild to Moderate Croup. Open Nurs J 2018; 11:241-261. [PMID: 29290883 PMCID: PMC5738747 DOI: 10.2174/1874434601711010241] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2017] [Revised: 10/25/2017] [Accepted: 11/10/2017] [Indexed: 12/04/2022] Open
Abstract
Background: Many randomised control trials and systematic reviews have examined the benefits of glucocorticoids for the treatment of croup in children, but they have reported mainly on dexamethasone as an oral treatment for croup. No systematic reviews have examined prednisolone alone. Aim: To determine in a systematic review of the literature whether a single dose of oral prednisolone is as effective as a single dose of dexamethasone for reducing croup symptoms in children. Search Strategy: A detailed search was conducted on the following databases: CINAHL, MEDLINE EBSCO, MEDLINE, OVID, PubMed, The Cochrane Library, ProQuest, EMBASE, JBI, Sum search, and OpenGrey. Study authors were contacted. Selection Criteria: Randomised Controlled Trials, clinical trials or chart reviews which examined children with croup who were treated with prednisolone alone, or when prednisolone was compared to a dexamethasone treatment and the effectiveness of the intervention was objectively measured using croup scores and re-attendance as primary outcomes. Data Collection and Analysis: Following PRISMA guidelines for systematic reviews, relevant studies were identified. Scores were graded agreed by two independent reviewers using QualSyst. Main Results: Four studies met the inclusion criteria, but were too heterogeneous to combine in statistical meta-analysis. The result suggests that although prednisolone appears as effective as dexamethasone when first given, it is less so for preventing re-presentation. Trial sample sizes were small, making firm conclusions difficult, however, a second dose of prednisolone the following day may be useful. More research including cost-benefit analysis is needed to examine the efficacy of prednisolone compared to dexamethasone.
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Affiliation(s)
- Anna Catherine Elliott
- Meneage Street Surgery, 100 Meneage Street, Helston, Cornwall TR17, 8RF, UK, 01326 555288
| | - Graham R Williamson
- Adult Nursing, School of Nursing and Midwifery, Plymouth University, Drake Circus, Plymouth, PL4 8AA. UK, 07976761858
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Infections of the Upper and Middle Airways. PRINCIPLES AND PRACTICE OF PEDIATRIC INFECTIOUS DISEASES 2018. [PMCID: PMC7152082 DOI: 10.1016/b978-0-323-40181-4.00028-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 10/24/2023]
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Ortiz-Alvarez O. La prise en charge du croup à la salle d’urgence. Paediatr Child Health 2017. [DOI: 10.1093/pch/pxx020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Lothrop N, Hussaini K, Billheimer D, Beamer P. Community-level characteristics and environmental factors of child respiratory illnesses in Southern Arizona. BMC Public Health 2017; 17:516. [PMID: 28545417 PMCID: PMC5445507 DOI: 10.1186/s12889-017-4424-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2016] [Accepted: 05/15/2017] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Lower respiratory illnesses (LRIs) and asthma are common diseases in children <5 years of age. Few studies have investigated the relationships between multiple, home-based social and environmental risk factors and asthma and LRIs in children. Of those that have, none have focused exclusively on children <5 years of age, who are more physiologically vulnerable and spend more time at home compared to older children. Further, no studies have done so at the community level. METHODS We modeled relationships between emergency department visits and hospitalization rates for asthma and LRIs for children <5 years and geographic risk factors, including socio-economic and housing characteristics, ambient air pollution levels, and population density in Maricopa and Pima Counties, Arizona, from 2005 to 2009. We used a generalized linear model with a negative binomial observation distribution and an offset for the population of very young children in each tract. To reduce multicollinearity among predictors, socio-economic characteristics, and ambient air pollutant levels were combined into unit-less indices using the principal components analysis (PCA). Housing characteristics variables did not exhibit moderate-to-high correlations and thus were not included in PCA. Spatial autocorrelation among regression model residuals was assessed with the Global Moran's I test. RESULTS Following the regression analyses, almost all predictors were significantly related to at least one disease outcome. Lower socio-economic status (SES) and reduced population density were associated with asthma hospitalization rates and both LRI outcomes (p values <0.001). After adjusting for differences between counties, Pima County residence was associated with lower asthma and LRI hospitalization rates. No spatial autocorrelation was found among multiple regression model residuals (p values >0.05). CONCLUSIONS Our study revealed complex, multi-factorial associations between predictors and outcomes. Findings indicate that many rural areas with lower SES have distinct factors for childhood respiratory diseases that require further investigation. County-wide differences in maternal characteristics or agricultural land uses (not tested here) may also play a role in Pima County residence protecting against hospitalizations, when compared to Maricopa County. By better understanding this and other relationships, more focused public health interventions at the community level could be developed to reduce and better control these diseases in children <5 years, who are more physiologically vulnerable.
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Affiliation(s)
- Nathan Lothrop
- Mel and Enid Zuckerman College of Public Health, University of Arizona, 1295 N. Martin Ave., PO 245210, Tucson, AZ 85724 USA
| | - Khaleel Hussaini
- Mel and Enid Zuckerman College of Public Health, University of Arizona, 1295 N. Martin Ave., PO 245210, Tucson, AZ 85724 USA
- Biomedical Informatics, College of Medicine, University of Arizona, Tucson, AZ 85724 USA
| | - Dean Billheimer
- Mel and Enid Zuckerman College of Public Health, University of Arizona, 1295 N. Martin Ave., PO 245210, Tucson, AZ 85724 USA
- BIO5 Institute, University of Arizona, Tucson, AZ 85724 USA
| | - Paloma Beamer
- Mel and Enid Zuckerman College of Public Health, University of Arizona, 1295 N. Martin Ave., PO 245210, Tucson, AZ 85724 USA
- BIO5 Institute, University of Arizona, Tucson, AZ 85724 USA
- Arizona Respiratory Center, University of Arizona, Tucson, AZ 85724 USA
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Abstract
Croup is one of the most common causes of upper airway obstruction in young children. It is characterized by sudden onset of barky cough, hoarse voice, inspiratory stridor and respiratory distress caused by upper airway inflammation secondary to a viral infection. Published guidelines for the diagnosis and treatment of croup advise using steroids as the mainstay treatment for all children who present to emergency department (ED) with croup symptoms. Dexamethasone, given orally as a single dose at 0.6 mg/kg, is highly efficacious in treating croup symptoms. Despite the evidence supporting the use of steroids as the cornerstone of croup treatment, there is significant practice variation among physicians treating croup in the ED. This practice point discusses evidence-based management of typical croup in the ED.
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Abstract
Human parainfluenza viruses (HPIVs) are single-stranded, enveloped RNA viruses of the Paramyoviridaie family. There are four serotypes which cause respiratory illnesses in children and adults. HPIVs bind and replicate in the ciliated epithelial cells of the upper and lower respiratory tract and the extent of the infection correlates with the location involved. Seasonal HPIV epidemics result in a significant burden of disease in children and account for 40% of pediatric hospitalizations for lower respiratory tract illnesses (LRTIs) and 75% of croup cases. Parainfluenza viruses are associated with a wide spectrum of illnesses which include otitis media, pharyngitis, conjunctivitis, croup, tracheobronchitis, and pneumonia. Uncommon respiratory manifestations include apnea, bradycardia, parotitis, and respiratory distress syndrome and rarely disseminated infection. Immunity resulting from disease in childhood is incomplete and reinfection with HPIV accounts for 15% of respiratory illnesses in adults. Severe disease and fatal pneumonia may occur in elderly and immunocompromised adults. HPIV pneumonia in recipients of hematopoietic stem cell transplant (HSCT) is associated with 50% acute mortality and 75% mortality at 6 months. Though sensitive molecular diagnostics are available to rapidly diagnose HPIV infection, effective antiviral therapies are not available. Currently, treatment for HPIV infection is supportive with the exception of croup where the use of corticosteroids has been found to be beneficial. Several novel drugs including DAS181 appear promising in efforts to treat severe disease in immunocompromised patients, and vaccines to decrease the burden of disease in young children are in development.
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Affiliation(s)
- Angela R Branche
- Department of Medicine, University of Rochester, Rochester, New York
| | - Ann R Falsey
- Department of Medicine, University of Rochester, Rochester, New York
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Lee DR, Lee CH, Won YK, Suh DI, Roh EJ, Lee MH, Chung EH. Clinical characteristics of children and adolescents with croup and epiglottitis who visited 146 Emergency Departments in Korea. KOREAN JOURNAL OF PEDIATRICS 2015; 58:380-5. [PMID: 26576182 PMCID: PMC4644766 DOI: 10.3345/kjp.2015.58.10.380] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/20/2014] [Revised: 10/10/2014] [Accepted: 11/07/2014] [Indexed: 11/27/2022]
Abstract
Purpose Croup is a common pediatric respiratory illness with symptoms of varying severity. Moreover, epiglottitis is a rare disease that can rapidly progress to life-threatening airway obstruction. Although the clinical course and treatments differ between croup and epiglottitis, they are difficult to differentiate on presentation. We aimed to compare the clinical characteristics of croup and epiglottitis in Emergency Department patients. Methods The 2012 National Emergency Department Information System database of 146 Korean Emergency Departments was used to investigate patients aged ≤18 years presenting with croup or epiglottitis. Results We analyzed 19,374 croup patients and 236 epiglottitis patients. The male:female sex ratios were 1.9:1 and 2.3:1 and mean ages were 2.2±2.0 and 5.6±5.8 years, respectively. The peak incidence of croup was observed in July and that of epiglottitis was observed in May. The hospitalization rate was lower in croup than in epiglottitis patients, and the proportion of patients treated in the intensive care unit was lower among croup patients. The 3 most common chief complaints in both croup and epiglottitis patients were cough, fever, and dyspnea. Epiglottitis patients experienced dyspnea, sore throat, and vomiting more often than croup patients (P<0.05). Conclusion Both groups had similar sex ratios, arrival times, 3 most common chief complaints, and 5 most common comorbidities. Epiglottitis patients had a lower incidence rate, higher mean age of onset, and higher hospitalization rate and experienced dyspnea, sore throat, and vomiting more often than croup patients. Our results may help in the differential diagnosis of croup and epiglottitis.
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Affiliation(s)
- Doo Ri Lee
- Department of Pediatrics, Seoul National University College of Medicine, Seoul, Korea
| | - Chang Hyu Lee
- Department of Pediatrics, National Medical Center, Seoul, Korea
| | - Youn Kyung Won
- Department of Pediatrics, National Medical Center, Seoul, Korea
| | - Dong In Suh
- Department of Pediatrics, Seoul National University College of Medicine, Seoul, Korea
| | - Eui-Jung Roh
- Department of Pediatrics, Sun General Hospital, Daejeon, Korea
| | - Mi-Hee Lee
- Department of Pediatrics, Incheon Medical Center, Incheon, Korea
| | - Eun Hee Chung
- Department of Pediatrics, National Medical Center, Seoul, Korea
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Bower J, McBride JT. Croup in Children (Acute Laryngotracheobronchitis). MANDELL, DOUGLAS, AND BENNETT'S PRINCIPLES AND PRACTICE OF INFECTIOUS DISEASES 2015. [PMCID: PMC7173542 DOI: 10.1016/b978-1-4557-4801-3.00061-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Petrocheilou A, Tanou K, Kalampouka E, Malakasioti G, Giannios C, Kaditis AG. Viral croup: diagnosis and a treatment algorithm. Pediatr Pulmonol 2014; 49:421-9. [PMID: 24596395 DOI: 10.1002/ppul.22993] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2013] [Accepted: 01/05/2014] [Indexed: 11/12/2022]
Abstract
Viral croup is a frequent disease in early childhood. Although it is usually self-limited, it may occasionally become life-threatening. Mild croup is characterized by the presence of stridor without intercostal retractions, whereas moderate-to-severe croup is accompanied by increased work of breathing. A single dose of orally administered dexamethasone (0.15-0.6 mg/kg) is the mainstay of treatment with addition of nebulized epinephrine only in cases of moderate-to-severe croup. Nebulized budesonide (2 mg) can be given alternatively to children who do not tolerate oral dexamethasone. Exposure to cold air or administration of cool mist are treatment interventions for viral croup that are not supported by published evidence, but breathing heliox can potentially reduce the work of breathing related to upper airway obstruction. In summary, corticosteroids may decrease the intensity of viral croup symptoms irrespective to their severity on presentation to the emergency department.
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Abstract
OBJECTIVES Croup is a common childhood respiratory illness that can result in hospitalization and significant morbidity. This study reviewed records of patients hospitalized with croup to determine characteristics associated with increased inpatient treatment and length of stay (LOS). METHODS Eligible patients were admitted between January 2006 and December 2010 and had discharge diagnosis of croup. Patients were included if they received either racemic epinephrine or systemic corticosteroids during their emergency department or hospital treatment. Patients were excluded for incomplete data on medication or vital signs timing. Hospitalization and treatment decisions were at the discretion of the treating physician. RESULTS The study analyzed 365 hospitalizations involving 327 patients, 72% male, 62% white, with median age of 16.7 months. Median LOS was 31.7 hours. Patients required racemic epinephrine treatments after hospitalization in 179 cases (49%; mean, 1.33 treatments; range, 0-13; median, 0), and 176 patients (48%) received a dose of systemic corticosteroids after hospital admission. Patients who required racemic epinephrine treatments after hospitalization were indistinguishable from those who did not, based on demographics, past history, or presenting vital signs. Patients with history of croup, history of intubation, or with oxygen saturation <95% on presentation all had increased LOS compared with those without these findings (P < .05). CONCLUSIONS Fifty-one percent of patients hospitalized with croup did not require inpatient racemic epinephrine treatments. Those with lower oxygen saturations on presentation or past history of croup or intubation were more likely to have prolonged or complicated hospital course.
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CD14 gene variants and their importance for childhood croup, atopy, and asthma. DISEASE MARKERS 2013; 35:765-71. [PMID: 24347797 PMCID: PMC3856132 DOI: 10.1155/2013/434920] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Download PDF] [Subscribe] [Scholar Register] [Received: 06/28/2013] [Revised: 10/01/2013] [Accepted: 10/09/2013] [Indexed: 11/17/2022]
Abstract
BACKGROUND The CD14 gene has an important role in the detection of inflammatory provoking pathogens and in the ensuing signaling of the innate immune response. We assessed the role of CD14 C-159T, G-1359T in the expression of asthma, croup, and allergy in Canadian school children of ages 6 to 14 years. METHODS Children attending schools in a rural community participated in a cross-sectional survey of respiratory health. Following consent, we conducted clinical assessments to collect buccal swabs for genotyping and perform skin prick testing (SPT) to determine atopic status. Genotyping and SPT results were available for 533 and 499 children, respectively. Separate multivariable analyses that included both polymorphisms were conducted for each phenotype. RESULTS The prevalence of asthma, allergy, and croup was 18.6%, 22.4%, and 6.6%, respectively. Children with the T/T variant of CD14 G-1359T were more likely to have physician diagnosed asthma (26.8%). Children with C/C variant of CD14 C-159T had a significantly lower prevalence of croup (2.6%). Haplotype analyses of the two CD14 polymorphisms showed that individuals with the T|T haplotype combination were significantly more likely to have asthma (P = 0.014). CONCLUSIONS In this study, CD14 variants are important for the expression of croup and asthma but not atopy.
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Schmidt AC, Schaap-Nutt A, Bartlett EJ, Schomacker H, Boonyaratanakornkit J, Karron RA, Collins PL. Progress in the development of human parainfluenza virus vaccines. Expert Rev Respir Med 2011; 5:515-26. [PMID: 21859271 DOI: 10.1586/ers.11.32] [Citation(s) in RCA: 86] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
In children under 5 years of age, human parainfluenza viruses (HPIVs) as a group are the second most common etiology of acute respiratory illness leading to hospitalization, surpassed only by respiratory syncytial virus but ahead of influenza viruses. Using reverse genetics systems for HPIV serotypes 1, 2 and 3 (HPIV1, 2 and 3), several live-attenuated HPIVs have been generated and evaluated as intranasal vaccines in adults and in children. Two vaccines against HPIV3 were found to be well tolerated, infectious and immunogenic in Phase I trials in HPIV3-seronegative infants and children and should progress to proof-of-concept trials. Vaccines against HPIV1 and HPIV2 are less advanced and have just entered pediatric trials.
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Affiliation(s)
- Alexander C Schmidt
- RNA Viruses Section, Laboratory of Infectious Diseases, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD 20892, USA.
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Seasonality patterns in croup presentations to emergency departments in Alberta, Canada: a time series analysis. Pediatr Emerg Care 2011; 27:256-60. [PMID: 21490537 DOI: 10.1097/pec.0b013e31821314b0] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Croup is a common pediatric respiratory illness presenting to the emergency department (ED) in the fall and winter months. Most cases are caused by parainfluenza viruses. We examine the monthly patterns of young children who made croup-related visits to EDs in Alberta, Canada. METHODS Emergency department visits were identified in provincial administrative databases to obtain all ED encounters for croup made by young children (aged ≤2 years) during 6 years (April 1, 1999, to March 30, 2005). Time series models (seasonal autoregressive integrated moving average) were developed to capture temporal and seasonal trends and predict future presentations. RESULTS Overall, 27,355 croup-related ED visits were made during the study period. More males (62%) than females presented, and most (43%) were younger than 1 year. Differences were observed in the number of visits made in odd and even years. Peak visits occurred in November for odd years and in February for other years. Strong seasonal patterns at 12 months were detected and included in the modeling. CONCLUSIONS We observed the presence of a clear biennial pattern of croup ED visits. The seasonal autoregressive moving average models and predictions offer insights into the epidemiology of croup-related visits to EDs and may be helpful in planning both research and resource needs.
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Abstract
BACKGROUND Since the initial publication of this systematic review in 1997, several randomized trials examining the benefit of glucocorticoids have been published. The objective of this review is to provide evidence to guide clinicians in their treatment of patients with croup by determining the effectiveness of glucocorticoids and to identify areas requiring future research. OBJECTIVES To determine the effect of glucocorticoids for children with croup. SEARCH STRATEGY We searched CENTRAL (2010, Issue 3), which contains the Cochrane Acute Respiratory Infections Group's Specialised Register, MEDLINE (1966 to July week 2, 2010) and EMBASE.com (1974 to July 2010). We also contacted authors of identified croup trials published in the last 10 years to inquire about additional published or unpublished trials. SELECTION CRITERIA Randomised controlled trials (RCTs) that examine children with croup and objectively measure the effectiveness of glucocorticoids. DATA COLLECTION AND ANALYSIS Two review authors identified studies for potential relevance based on the review of the title and abstract (when available). Two review authors independently reviewed studies for relevance using a priori inclusion criteria and assessed trial quality. Differences were resolved by consensus. One review author extracted data using a structured form and another review author checked the results for accuracy. We performed standard statistical analyses. MAIN RESULTS Thirty-eight studies were included (n = 4299). Glucocorticoids were associated with an improved Westley score (maximum 17 points) at six hours with a mean difference of -1.2 (95% confidence interval (CI) -1.6 to -0.8) and at 12 hours -1.9 (95% CI -2.4 to -1.3); at 24 hours this improvement was no longer significant (-1.3, 95% CI -2.7 to 0.2). Fewer return visits and/or (re)admissions occurred in participants treated with glucocorticoids (risk ratio (RR) 0.5; 95% CI 0.3 to 0.7). Length of time spent in accident and emergency or hospital (mean difference 12 hours, five to 19 hours) was significantly decreased for participants treated with glucocorticoids. Use of epinephrine decreased for children treated with a glucocorticoid (risk difference 10%; 95% CI 1 to 20). AUTHORS' CONCLUSIONS Dexamethasone and budesonide are effective in relieving the symptoms of croup as early as six hours after treatment. Fewer return visits and/or (re)admissions are required and the length of time spent in hospital is decreased. Research is required to examine the most beneficial method for disseminating croup practice guidelines and to increase the uptake of evidence.
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Affiliation(s)
- Kelly F Russell
- Department of Pediatrics, University of Alberta, Aberhart Centre One, 11402 University Ave, Edmonton, Alberta, Canada, T6G 2J3
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