A Christmas Case of The Month!!

Welcome To Our Christmas Case!!!

Merry Christmas paeds family!!! We hope that you have a lovely time. To help build up that Christmas hype, have a go at our case below – Rudolf and Noel really need your awesome medicine knowledge – they may even put in a good word with Santa for you 😉

The Case

Rudolf dashes to A&E concerned that his 2-month-old son, Noel, has been singing along to Christmas carols. You take a thorough history
and elicit that he has been ‘singing’ since birth. Noel was born at term, is feeding well and gaining weight. On examination you realise the ‘singing’ is in fact an inspiratory stridor. Have a think about differentials for stridor in an infant before moving on to the next question…

Which of the following would be your top differential? A) Laryngomalacia B) Anaphylaxis C) Foreign body D) Croup E) Bacterial tracheitis

Laryngomalacia – most common congenital cause of stridor.
Anaphylaxis – possible but unlikely as there is no history of Noel being unwell and he is only 2 mo so will not have been weaned yet.
Foreign body – again possible and should be considered. The key history point is that the stridor has been present since birth rather than of sudden onset as would be expected with FB inhalation. Nb. Do not rule it out purely based on absence of a choking episode as often there is no witnessed choking episode.
Croup – infectious causes are far less common in infants. ‘Barking’ cough, not singing.
Bacterial tracheitis – often referred to as pseudomembranous croup. Same for croup but also very unlikely as there is no mention of Noel being very unwell. Hx of ‘double sickening’- when a viral croup becomes superseded by a bacterial infection.

How would this condition be managed?

Laryngomalacia = “floppy cartilage” – think of it as delayed development of the larynx such that during inspiration the supraglottic airway collapses.
Laryngomalacia typically resolves within 1 – 2 years as the cartilage hardens so conservative management is the mainstay of treatment with feeding support.
Complications of laryngomalacia include risk of choking and FTT. Severe cases (~10%) surgery (supraglottoplasty) is required.

Reassured that Noel is doing well, Rudolf sets about his jobs for the year. A few weeks later on Christmas day, Rudolf is back in A&E concerned this time about his 18-mo-old daughter, Ivy. She was awake all Christmas Eve with a barking cough which first started 2 days ago. There is a harsh stridor when she runs around but not at rest. Her temperature is 37.8°C.

Which features of the history help you determine if Ivy has croup or epiglottitis?

Croup	Epiglottitis
Barking cough typically worse at night	No cough
Mild fever	High fever
Progresses over days	Progresses over hours
Prodromal coryzal symptoms Hoarse voice common	Missed HiB vaccine
Age: 6mo – 6yrs	Age: 2yrs – 6yrs
In severe cases: may be uninterested in surroundings with stridor at rest and signs of respiratory distress	In severe cases: Drooling saliva Reluctant to speak

Your consultant is very impressed with your ability to differentiate between croup and epiglottitis and asks you to examine Ivy for signs of respiratory distress – what will you look out for?

Raised respiratory rate
Tracheal tugging
Nasal flaring
Use of accessory muscles – head bobbing, shoulder movement, tummy breathing
Subcostal & / or intercostal recession (later seen more in infants)

What are the main causative pathogens of Croup and Epiglottitis respectively?

Parainfluenzae and H. influenzae type B – croup is typically viral whilst epiglottitis is typically bacterial
Parainfluenzae and Respiratory syncytial virus (RSV)
Respiratory syncytial virus and pertussis
influenzae type B and Parainfluenzae
Respiratory syncytial virus and H. influenzae type B

What is the management for Croup?

Respiratory distress worsens with agitation so ensure the chid is comfortable – ideally in the lap of parent / carer.
Determine the severity:
- Mild: barking cough but no stridor or sternal/intercostal recession at rest
- Moderate: barking cough with stridor or sternal/intercostal recession at rest
- Severe: barking cough with stridor or sternal/intercostal recession at rest and agitation / lethargy
- Impending respiratory failure: pallor, fatigue, decreased level of consciousness, asynchronous chest wall and abdominal movement i.e., tummy goes out when chest goes in, tachycardia, RR> 70 (severe respiratory distress) à bleep the ENT Reg +/- anaesthetist now!

(see Westley Croup Severity Score for more information)

Consider need for admission…
Children with moderate or worse croup should be admitted.
Consider admission for mild croup if <3mo, significant lung disease or CHD, immunodeficiency, neuromuscular disorder e.g., cerebral palsy, or if issues with returning to hospital quickly or any of the usual red flags such as insufficient fluid intake / no wet nappies.
Oxygen if severe
All children with croup are treated with a single dose of oral dexamethasone (0.15mg/kg) unless difficulty with oral then inhaled budesonide.

You wisely decide to send Ivy home after a full assessment and one dose of oral dex, what are the important things for Rudolph to look out for? i.e., what should you safety-net for?

Expect resolution within 48hrs
Return to hospital if:
- Child is very pale or unusually sleepy
- Child is having a lot of trouble breathing (explain recession etc.)
- Child is having stridor at rest
- Child starts to drool or has difficulty swallowing