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Chapter 2 Index
A. Evaluation by system:
1. General 2. HEENT
--Otitis Media:
Classification, Rx and Complications
--Pediatric ENT:
1. When to Refer for Tubes
2. Laryngeal Abnormalities
--The Treatment of Otorrhea
--Eye Problems of Children
--Allergic Rhinitis
--Sinusitis vs. Purulent Rhinitis vs. URI
--“Treatment” of the Common Cold
--Frequently Used OTC Medications for the Common Cold
--Facial Nerve Palsy in Pediatrics
--Strep Throat
--Other Streptococcal Infections in Children |
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Croup: Differential Diagnosis and Treatment
Introduction: Croup is the most common cause of upper
airway obstruction in children between 6 months and 6 years of age. Almost
all children with croup can be treated as outpatients. There may be an
association with asthma and other lower respiratory tract infections. This
is based on the presence of hyperreactive airways, not true atopy.
Possible
Medications To Be Used in Treatment of Viral Croup:
- **IM Dexamethasone: the standard: 0.6 mg/kg dose
- PO Steroids alone: no question that helps modify severe croup, which
requires hospitalization. Studies of inpatients (Acta Paediatr.
1988;77:99-104). Dose of 0.15 mg/kg is just as effective as 0.6 mg/kg of
po dexamethasone. (Pediatric Pulmonology 95;20:362-8.). IM route still
preferred.
- Nebulized Dexamethasone: not effective. (Archives Ped & Ad
Med. 1996;150:349-355.)
- Nebulized Budesonide:
- Budesonide as good as adrenaline: no difference (Pediatrics
1996;97:722-5);
- combined with Dexamethasone po (0.6 mg/kg): 84% did well,
compared to 56% who received Dexamethasone po alone. (Pediatrics
1996;97:463-466)
- more recently: (JAMA 98;279:1629-32): po dexamethasone and
neb bud: no difference
- compared with IM Dexamethasone and placebo: both better
than placebo; IM Dexamethasone is better than budesonide: (NEJM
98;339:498-503)
- Racemic Epinephrine: Dose (0.5 ml of 2.25% epi diluted in 2.5 ml of
saline). Many worry about giving this as outpatient, since the rebound
from it can be so severe. Three recent articles: conclude: OK to give if
watch for 3-4 hours after treatment. If need two treatments: admit.
Question that must be answered: is it reasonable to keep children hanging
around an ER for 3-4 hours after being treated?
Differential
Diagnosis of Croup:
- Viral Croup vs spasmodic croup (younger age – 1-3 years of age, allergic, psychological factors, GER
associated. Spasmodic often occurs in middle of the night)
- Epiglottitis (H. Flu type B): can still occur; signs: cyanosis, drooling,
fever: age 2-7 yrs
- Bacterial Tracheitis (staph aureus): can be just as lethal as epiglottitis; toxicity
of child, WBC and diff, nature of illness all must be taken into account.
- Organic
problems such as subglottic stenosis after prolonged ET tube placement,
laryngeal webs, etc. These should be considered in recurrent
croup is recurrent or stridor at rest.
- Foreign
bodies
- Anaphylaxis with angioedema of the subglottic area.
Outpatient
Treatment of Mild Croup: Still Controversial:
General
treatment: hydration, humidification (cool mist, not hot steam), fever
control. No help from decongestants, antihistamines and
antibiotics, but these are used commonly.
Role of
steroids is not clear in mild croup: po prednisone, po dexamethasone,
nebulized budesonide, IM steroids; also unclear about whether
should be used in the child who is now well, but had croup the
night before. A lot of IM dexamethasone is given for children
with croup in physicians’ offices.
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