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Background and Objectives: Croup and bronchiolitis are common reasons for hospitalization in children, and the role of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection on utilization outcomes for these conditions is not well understood. To compare health care utilization including the rates of hospitalization, readmission, length of stay, and ICU admission for croup and bronchiolitis in children with and without evidence of concurrent SARS-CoV-2 infection over the pandemic period., Methods: This retrospective cohort study used inpatient and outpatient electronic health record data from PEDSnet institutions to examine health services use for children aged 30 days to 14 years with SARS-CoV-2 infection and diagnosed with croup or bronchiolitis. The time frame (March 2020-May 2022) was divided into predelta, delta, and omicron variant periods. Multivariable mixed effects logistic and log gamma regression models were used to calculate adjusted odds ratios for factors linked to utilization outcomes for children with versus without SARS-CoV-2 infections. Disease burden was described by variant time period., Results: Across all time periods, among subjects with croup and bronchiolitis, 9.65% of croup patients and 3.92% of bronchiolitis patients were SARS-CoV-2-positive. The omicron variant period had the highest number of SARS-CoV-2 cases for both croup and bronchiolitis. After controlling for patient-level variables and hospital variability, we found no statistically significant differences in utilization outcomes comparing children with and without SARS-CoV-2., Conclusions: Pediatric patients with croup and bronchiolitis and positive SARS-CoV-2 polymerase chain reaction testing did not exhibit a significant increase in hospital and ICU admissions, which may have implications for future staffing models and public health recommendations., Competing Interests: CONFLICT OF INTEREST DISCLOSURES: Dr Rao reports previous grant support from GSK and Biofire. Dr Bakel reports current grant support from Pfizer. Dr Jhaveri is a consultant for AstraZeneca, Seqirus, and Dynavax; receives an editorial stipend from Elsevier and the Pediatric Infectious Diseases Society; and receives royalties from Up To Date/Wolters Kluwer. The other authors have indicated they have no conflicts of interest relevant to this article to disclose., (Copyright © 2024 by the American Academy of Pediatrics.)

Objectives: To assess the impact of croup guidelines on healthcare utilization and association between guideline-recommended racemic epinephrine (RE) treatments and admission., Methods: Cross-sectional study of children ≥3 months to ≤8 years with croup diagnosis (International Classification of Diseases, 10th Revision) from 38 hospitals within the Pediatric Health Information System between January 1, 2019 and June 30, 2022. Guidelines were categorized by minimum number of RE treatments recommended before admission. Exclusion criteria included complex chronic or croup mimicking conditions, alternate respiratory diagnoses, and direct admissions or transfers. Primary outcomes were admission rates and standardized costs. Outcomes were compared by guideline availability and different admission thresholds. Mixed effects regression was adjusted for age, sex, race, payer, previous croup encounters, and year., Results: Twenty hospitals (52.6%) had guidelines. Fourteen recommended 2 RE treatments and 3 recommended 3 RE treatment before admission. Among 121 284 croup encounters, overall mean admission rate was 5.7% (range 0.6% to 18.5%). Hospitals with guidelines demonstrated lower unadjusted admission rate (4.6% vs 6.6%; mean difference -2.0, 95% confidence interval -2.3 to -1.7) and higher costs ($704 vs $651; mean difference 53, 95% confidence interval 43 to 63) compared with hospitals without guidelines. Hospitals with guidelines recommending 3 RE treatments demonstrated similar unadjusted mean admission rate (5.1%) and lower costs ($658 vs $713) compared with hospitals with guidelines recommending 2 RE treatments. After adjustment, all above-mentioned differences were not statistically significant., Conclusions: Many children's hospitals lack guidelines for croup. Admission rates and costs were not significantly different between hospitals with or without guidelines after adjusting for confounders., (Copyright © 2023 by the American Academy of Pediatrics.)

Background: Croup is one of the most common respiratory complaints in pediatric emergency departments (EDs), yet little is known about clinical practice guidelines (CPGs) for this condition., Objectives: To describe variation in CPGs across US children's hospitals., Methods: We describe the prevalence and features of CPGs among hospitals that submit data to the Pediatric Health Information System. Each hospital was contacted between January 10, 2022, and April 25, 2022, for their most recent croup CPG and any revisions. Characteristics reported were based on the most recent CPG revision. Characteristics included treatment recommendations, utilization measures, ED observation times, and admission criteria. Interrater reliability between reviewers was reported as percentage agreement., Results: Thirty-eight hospitals (79.2%) responded to our query, of which 20 (52.6%) had croup CPGs. Interrater reliability was moderate-high for categorizing the indication for racemic epinephrine (RE) (19 of 20; 95%), the minimum number of RE doses recommended before admission (15 of 20; 75%), and ED observation time (19 of 20; 95%), and was 100% for all other characteristics. Three CPGs (15.0%) recommended 1 RE dose, 14 (70.0%) recommended 2 RE doses, and 3 (15.0%) recommended 3 RE doses before hospital admission. Thirteen (65%) CPGs recommended RE for stridor at rest, whereas 7 (30%) recommended RE for any degree of stridor. Fourteen (70%) CPGs recommended an ED observation time <2 hours, 3 (15%) recommended 2 to 4 hours, and 2 (10%) recommended >4 hours. Few CPGs (15%) recommended use of standardized croup clinical scores., Conclusions: Substantial variation exists among croup CPGs. Our results may inform future efforts to standardize croup CPGs across centers., (Copyright © 2023 by the American Academy of Pediatrics.)

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., Competing Interests: POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose., (Copyright © 2020 by the American Academy of Pediatrics.)

Competing Interests: POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.

Objectives: There are no data to inform the ideal length of in-hospital observation after symptom improvement or to inform the ideal dexamethasone dose in critically ill children with croup. We describe a cohort of critically ill children with croup who rebound (have return of symptom(s) after meeting hospital discharge criteria) and examine the association between the cumulative dexamethasone dose before PICU discharge and both the odds and timing of rebound., Methods: In this single-center retrospective cohort study of subjects 6 months to 13 years of age admitted to the PICU with a primary diagnosis of croup, we employed multivariable logistic regression to evaluate the association between cumulative pre-PICU discharge dexamethasone dose and rebound. In the model, we controlled for subject age and sex, insurance, season, and history of prematurity, croup, or intubation. Kaplan-Meier curves were used to compare time to rebound between subjects receiving ≤2 standard (0.6 mg/kg) doses and those receiving >2 standard doses of dexamethasone before PICU discharge., Results: Data were analyzed over 69 months (January 2011-October 2016), and 275 unique subjects met inclusion criteria. The median cumulative dose of dexamethasone in the hospital was 1.57 mg/kg (interquartile range 0.98-2.63). Thirty-seven percent ( n = 102) of subjects developed rebound croup symptoms after meeting hospital discharge criteria. The median time to rebound was 13.1 hours (interquartile range 6.1-23.7). There was no association between cumulative pre-PICU discharge dexamethasone dose and the odds (odds ratio = 1.00; 95% confidence interval 0.83-1.19; P = .96) or timing of rebound., Conclusions: A clinically significant number of critically ill patients with croup rebounded. Total pre-PICU discharge dexamethasone dose did not predict either the odds or timing of rebound., Competing Interests: POTENTIAL CONFLICT OF INTEREST: Dr Dempsey serves on advisory boards for Merck and Pfizer; she does not receive any research funding from these companies; the other authors have indicated they have no potential conflicts of interest to disclose., (Copyright © 2019 by the American Academy of Pediatrics.)

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.