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Croup is a common respiratory illness in children under 5 years, primarily caused by viral infections. Symptoms include inspiratory stridor, barking cough, and hoarseness due to inflamed vocal cords. Diagnosis is based on symptoms difficulty breathing, stridor, chest in-drawing voice changes and head nodding. Severity ranges from mild to severe cases. This study aimed to explore variations in croup and factors contributing to its recurrence in children. This retrospective longitudinal study analyzed health records from the Pediatric Practice "Vitalino" in Veles, North Macedonia, from 2016 to 2022. It included children aged 0-5 years who had croup at least once. The sample was substantial and representative, allowing for a thorough examination of potential correlations and trends in croup occurrence. Among 707 studied children, 254 had croup, with a prevalence of 35.9% over seven years or 5.1% per year. Females had lower odds of recurrent croup, while males had higher odds, but the differences were not statistically significant. Atopic dermatitis and bronchiolitis exposure were significantly associated with croup in both genders. The study provides insights into the prevalence, distribution of croup and associated conditions in young children. The significant associations of atopic dermatitis and bronchiolitis suggest a link between these conditions and recurrent croup. Considering these strong associations, we can conclude that bronchiolitis and croup should be included in the trajectory of the atopic march., (© 2024 Valentina Risteska Nejashmikj., published by Sciendo.)

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.)

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., Competing Interests: The authors have no potential conflicts of interest to disclose., (© 2024 The Korean Academy of Medical Sciences.)

Introduction: The fifth wave of the coronavirus disease 2019 (COVID-19) pandemic in Hong Kong was dominated by the Omicron variant, which may cause more upper airway involvement in children. This study was performed to identify any associations between the Omicron variant of COVID-19 and croup in children., Methods: This retrospective study reviewed the electronic medical records of patients admitted to Tuen Mun Hospital in Hong Kong from 1 January 2018 to 31 March 2022 under the diagnostic code for croup (J05.0 in the International Classification of Diseases 10th Edition). Patients were categorised into three groups according to their admission periods, namely, non-COVID-19, COVID-19-pre-Omicron, and COVID-19-Omicron groups. Disease associations and severity were compared according to incidence, Westley Croup Score, length of hospital stay, medication use, respiratory support, and intensive care unit admissions., Results: The COVID-19 incidence among patients with croup was significantly higher in the COVID-19-Omicron group than in the COVID-19-pre-Omicron group (90.0% vs 2.0%; P<0.001). Compared with patients in the COVID-19-pre-Omicron and non-COVID-19 groups, patients in the COVID-19-Omicron group also had a higher Westley score (moderate and severe disease in the COVID-19-Omicron group: 56.7%; COVID-19-pre-Omicron group: 22.0%, P=0.004; non-COVID-19 group: 24.8%, P<0.001), longer median hospital stay (COVID-19-Omicron group: 3.00 days; COVID-19-pre-Omicron group: 2.00 days, P<0.001; non-COVID-19 group: 2.00 days, P=0.034), and higher mean dexamethasone requirement (COVID-19-Omicron group: 0.78 mg/kg; COVID-19-pre-Omicron group: 0.49 mg/kg, P<0.001; non-COVID-19 group: 0.58 mg/kg, P=0.001)., Conclusion: The Omicron variant of COVID-19 is associated with croup and can cause more severe disease in Hong Kong children., Competing Interests: Both authors have disclosed no conflicts of interest.

Objective: Croup due to infection with the omicron variant of COVID is an emerging clinical entity, but distinguishing features of omicron croup have not yet been characterized. We designed a study to compare the clinical features of croup patients presenting to the pediatric emergency department pre-COVID pandemic with COVID-positive croup patients who presented during the initial omicron surge., Methods: This was a retrospective observational cohort study of children 0 to 18 years old who presented to our urban, tertiary care pediatric emergency department with symptoms of croup. The study compared a cohort of croup patients who presented in the year before the onset of the COVID pandemic to a cohort of COVID-positive croup patients who presented during the initial omicron surge. The primary outcomes included illness severity and treatments required in the emergency department. The secondary outcome was hospital admission rate., Results: There were 499 patients enrolled in the study, 88 in the omicron croup cohort and 411 in the classic croup cohort. Compared with the classic croup patients, omicron croup patients were more likely to present with stridor at rest (45.4% vs 31.4%; odds ratio [OR], 1.82; confidence interval [CI], 1.14-2.91) and hypoxia (3.4% vs 0.5%; OR, 7.22; CI, 1.19-43.86). Omicron croup patients required repeat dosing of inhaled epinephrine in the emergency department more often (20.4% vs 6.8%; OR, 3.51; CI, 1.85-6.70), and they were more likely to require respiratory support (9.1% vs 1.0%; OR, 10.18; CI, 2.99-34.60). Admission rates were significantly higher for omicron croup patients than for classic croup patients (22.7% vs 3.9%; OR, 7.26; CI, 3.58-14.71), and omicron croup patients required intensive care more frequently (5.7% vs 1.5%; OR, 4.07; CI, 1.21-13.64)., Conclusions: Pediatric patients with omicron croup develop more severe disease than do children with classic croup. They are more likely to require additional emergency department treatments and hospital admission than patients with croup before the COVID pandemic., Competing Interests: Disclosure: The authors declare no conflict of interest., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

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., (Copyright © 2023 by the American Academy of Pediatrics.)

In this retrospective analysis, we describe weekly croup and corresponding viral prevalence patterns in a pediatric quaternary care system in metropolitan Atlanta. We characterize a series of 24 patients with croup associated with SARS-CoV-2 infection and show that this clinical presentation increased substantially in frequency during the period of high Omicron vs Delta transmission., (© The Author(s) 2022. Published by Oxford University Press on behalf of The Journal of the Pediatric Infectious Diseases Society.)

Objective: This pilot study aims to identify potential predictors of postadmission interventions of hospitalized croup patients and derive a risk model aimed at reducing hospitalizations for croup., Methods: Data were collected on all croup hospitalizations for patients aged 1 month to 17 years admitted through a community hospital's emergency department (ED) between 2012 and 2017. Potential predictors were obtained from the electronic medical records including demographics, vital signs, ED length of stay, preintervention and postintervention Westley Croup Score (WCS), number of racemic epinephrine nebulizations administered, time to dexamethasone administration, preexisting conditions, and additional interventions during hospitalization. Statistical analysis used the outcome "patient received racemic epinephrine after hospital admission (yes/no)" to identify characteristics of the child or ED visit associated with that outcome. Preliminary analyses using stepwise logistic regression, tree models, and random forests suggested predictors, interactions among predictors, and the form of their association with the outcome. A final analysis used logistic regression., Results: A total of 116 croup admissions were included, of which 19 (16%) received racemic epinephrine posthospitalization. These characteristics were identified as having some predictive power: sex, preexisting conditions, and preintervention and postintervention WCS, along with the interaction between sex and postintervention WCS. Logistic regression estimated an equation describing the probability of postadmission intervention, permitting the choice among admission thresholds giving different sensitivities and specificities., Conclusions: There appear to be promising predictors in croup patients presenting to the ED, which might help stratify risk for interventions after the ED encounter and thus reduce the number of potentially avoidable admissions., Competing Interests: Disclosure: The authors declare no conflict of interest., (Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.)

We describe three previously healthy children, admitted from our emergency department (ED) to our free-standing children's hospital, as the first documented cases of croup as a manifestation of SARS-CoV-2 infection. All three cases (ages 11 months, 2 years, and 9 years old) presented with non-specific upper-respiratory-tract symptoms that developed into a barky cough with associated stridor at rest and respiratory distress. All were diagnosed with SARS-CoV-2 by polymerase chain reaction testing from nasopharyngeal samples that were negative for all other pathogens including the most common etiologies for croup. Each received multiple (≥3) doses of nebulized racemic epinephrine with minimal to no improvement shortly after medication. All had a prolonged period of time from ED presentation until the resolution of their stridor at rest (13, 19, and 21 h). All received dexamethasone early in their ED treatment and all were admitted. All three received at least one additional dose of dexamethasone, an atypical treatment occurrence in our hospital, due to each patient's prolonged duration of symptoms. One child required heliox therapy and admission to intensive care. All patients were eventually discharged. Pathogen testing is usually not indicated in croup, but with "COVID-19 croup," SARS-CoV-2 testing should be considered given the prognostic significance and prolonged quarantine implications. Our limited experience with this newly described COVID-19 croup condition suggests that cases can present with significant pathology and might not improve as rapidly as those with typical croup., (Copyright © 2021 Elsevier Inc. All rights reserved.)

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.)

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., (Copyright © 2019 Elsevier B.V. All rights reserved.)

Objectives: To assess (1) the accuracy of child immunization status documented by providers at hospital presentation for acute respiratory illness and (2) the association of provider-documented up-to-date (UTD) status with immunization receipt during and after hospitalization., Methods: We conducted a retrospective cohort analysis of children ≤16 years old treated for asthma, croup, bronchiolitis, or pneumonia at a children's hospital between July 2014 and June 2016. Demographics, clinical characteristics, and provider-documented UTD immunization status (yes or no) at presentation were obtained from the medical record. We compared provider-documented UTD status to the gold standard: the child's UTD status as documented in the Washington State Immunization Information System (WAIIS). The sensitivity, specificity, and positive predictive value of provider-documented UTD status were calculated. We assessed the association of provider-documented UTD status and immunization during and within 30 days posthospitalization using multivariable logistic regression., Results: Among 478 eligible children, 450 (94%) had provider-documented UTD status at hospital presentation and an active WAIIS record. Overall, 92% and 42% were UTD by provider documentation and WAIIS records, respectively, with provider-documented UTD status having 98.4% sensitivity (95% confidence interval [CI]: 95.4%-99.7%), 12.2% specificity (95% CI: 8.5%-16.8%), and 44.6% positive predictive value (95% CI: 39.7%-49.5%). Per WAIIS records, 20% and 44% of children who were due for vaccines received a vaccine during or within 30 days posthospitalization, respectively. There was no significant association between provider-documented UTD status and immunization during or after hospitalization., Conclusions: Provider-documented UTD immunization status at hospital presentation for children with respiratory illnesses overestimates UTD status, creating missed opportunities for immunization during and after hospitalization., Competing Interests: POTENTIAL CONFLICT OF INTEREST: Dr Hofstetter previously received research support from Pfizer Independent Grants for Learning and Change; the other authors have indicated they have no potential conflicts of interest to disclose., (Copyright © 2018 by the American Academy of Pediatrics.)

Objectives: Croup, or laryngotracheobronchitis, is a common disease in childhood. On the other hand, to our knowledge, there are only 14 cases in six English literatures describing adult croup (AC). The clinical features of AC have not been well known., Methods: We conducted a retrospective analysis of medical records of 18 patients with AC during the period from 2008 to 2016., Results: None of the 18 patients required an urgent airway intervention. Univariate analysis indicated that the duration of symptoms was significantly longer in patients with cough (p < .01) and younger patients (age < 60, p = .037). The duration of subglottic edema was significantly longer in female (p = .035), patients with high levels of CRP (≥1 mg/dL, p = .049), and patients with cough symptom (p = .035)., Conclusions: Female, young age (<60 years), the symptom of cough, and high levels of CRP should be recognized as signs of prolonged AC. It is important to confirm the diagnosis of AC by laryngoscopic examination, which also help to avoid airway intervention.

Aim: This study examined whether prenatal phthalate exposure was associated with lower or upper airway inflammation in infants., Methods: From 2007 to 2010, we used liquid chromatography-tandem mass spectrometry, adjusted for creatinine, to analyse 14 phthalate metabolites and one phthalate replacement in the urine of 1062 Swedish mothers at a median of 10 weeks of pregnancy. This was used to determine any associations between prenatal phthalate exposure and croup, wheezing or otitis in their offspring until 12 months of age, using logistic regression, adjusted for potential confounders., Results: There were significant associations between phthalate metabolites of butyl-benzyl phthalate (BBzP) and di-ethyl-hexyl phthalate (DEHP) concentrations in maternal prenatal urine and croup in 1062 infants during the first year of life, when adjusted for potential confounders. A dose-response relationship was found between prenatal phthalates exposure and maternal reported croup in the children, with a significant association in boys. There was no clear indication with regard to associations between prenatal phthalate exposure and wheezing or otitis media in the children during the first year of life., Conclusion: Our analysis suggests that exposure to BBzP and DEHP phthalates was associated with maternal reports of croup in infants up to 12 months of age., (©2018 Foundation Acta Paediatrica. Published by John Wiley & Sons Ltd.)

Objective: Introduction: Some studies have found associations between maternal occupational hazards during pregnancy and allergy in children. The role of allergy and maternal occupational hazards in predisposition to laryngotracheitis (LT) needs to be clarified. The aim: Objective of the research was to evaluate the possibility of relationship between maternal occupational hazards during pregnancy and allergy in the first year of life in children with LT and recurrent laryngotracheitis (RLT), as well as the debut timing of LT and RLT depending on allergy., Patients and Methods: Materials and methods: A questionnaire was used to obtain life history of 405 children aged 6-14 years: 133 children with LT (1-3 episodes of LT), 74 children with RLT (4 or more episodes of LT) and 198 age matched children of control group., Results: Results: The percentage of children with allergy in case of RLT was 48,6% and exceeded the percentage of children with allergy in case of LT and control group in 1,7 and 2,1 times, correspondingly (p<0,01). The tendency (p=0,06) towards increase of the percentage of children with allergy among children with RLT in case of maternal occupational health hazards has been revealed. Among children with RLT percentage of those who had allergy and the debut timing in the first year of life exceeded 3 times the corresponding percentage in children with LT (p<0,01). There was no difference in the debut timing of LT and RLT between children with and without allergу., Conclusion: Conclusions: Maternal occupational health hazards during pregnancy and allergy in the first year of life may be considered as risk factors of RLT in children.

Background: Air pollution is a severe problem in Poland, with Kraków area being among the regions with the worse air quality. Viral croup or pseudocroup is a common childhood disease that may manifest with severe upper respiratory tract obstruction. Our aim was to evaluate the associations between incidence and severity of viral croup symptoms among children living in Kraków area, Poland, and air pollution., Methods: The retrospective cross-sectional study included Kraków area residents <18 years of age admitted to the Emergency Department of St. Louis Children Hospital in Kraków, Poland over 2-year period. Daily mean concentrations of air pollutants: particulate matter (PM10 and PM2.5), nitric oxides (NOx), carbon oxide (CO), sulfur dioxide, ozone, and benzene were retrieved from public database of measurements performed at three local stations. Numbers of cases of viral croup per week were correlated with weekly mean concentrations of air pollutants. Mean air temperature was treated as a cofactor., Results: During the studied period, mean concentrations of PM10, PM2.5, and NOx exceeded the allowable levels (yearly means) specified by Polish law regulations. Significant positive correlations of moderate strength were observed between weekly mean concentrations of most air pollutants, especially PM10, PM2.5, CO and benzene, and numbers of cases of viral croup recorded per week, confirmed in the analysis restricted to non-holiday period and to winter months only. The correlations between NOx, CO, benzene and croup prevalence were independent of temperature in non-holiday period., Conclusions: Our results support adverse impact of air pollution on children's respiratory health.

Importance: The etiology of recurrent croup is often anatomic. Currently there is no set criteria for determining who should undergo diagnostic bronchoscopy and which patients are at most risk for having a clinically significant finding. Few studies have addressed these questions., Objective: To identify risk factors for clinically significant findings on bronchoscopy in children with recurrent croup and the frequency of bronchoscopy findings in general., Data Sources: PUBMED, Ovid MEDLINE, EMBASE., Study Selection: Articles addressing bronchoscopy in children with recurrent croup, up to July 2016, were reviewed. Related keywords and medical subject headings were used during the search. The abstracts were reviewed to determine suitability for inclusion based on a set of criteria. Manual crosscheck of references was performed., Data Extraction: We analyzed the bronchoscopy findings of individual patients in each study and their associated risk factors when available., Results: We reviewed 11 articles, published between 1992 and 2016, including 885 patients (654 males, 237 females). Only 5 studies, including 455 patients, had sufficient data for meta-analysis. Our study revealed that the three most common bronchoscopy findings were subglottic stenosis, reflux changes, and broncho/tracheomalacia. Only 8.7% of patients were noted to have clinically significant findings on bronchoscopy. Meta analysis showed an association between significant bronchoscopy findings and History of Intubation [OR = 5.17, 95% CI 2.65-10.09], Inpatient Consultation [OR = 4.01, 95% CI 1.44-11.20], Age < 3 [OR = 3.22, 95% 1.66-6.27], Age < 1 [OR = 2.86, 95% CI 1.28-6.40], and Prematurity [OR = 2.90, 95% CI 1.39-6.06]. Our study found a high incidence of a History of GERD (20%) and Asthma/Allergies (35%) among patients with recurrent croup, but these variables did not reach statistical significance in patients with significant bronchoscopy findings ([OR = 1.62, 95% CI 0.79-3.30], [OR = 0.57, 95% CI 0.30-1.08] respectively)., Conclusion: The risk factors most associated with clinically significant bronchoscopy findings in recurrent croup are Intubation, Inpatient Consultation, Age < 3, Age <1, and Prematurity. A History of GERD and Asthma/Allergy, though highly prevalent in recurrent croup patients, were not statistically associated with significant bronchoscopy findings., Relevance: The results should guide physicians in selecting which recurrent croup patients are most at risk for significant findings and thus may warrant bronchoscopy., (Copyright © 2016 Elsevier Ireland Ltd. All rights reserved.)

Background: Parainfluenza virus (PIV) is the second leading cause of hospitalization for respiratory illness in young children in the United States. Infection can result in a full range of respiratory illness, including bronchiolitis, croup, and pneumonia. The recognized human subtypes of PIV are numbered 1-4. This study calculates estimates of PIV-associated hospitalizations among U.S. children younger than 5 years using the latest available data., Methods: Data from the National Respiratory and Enteric Virus Surveillance System were used to characterize seasonal PIV trends from July 2004 through June 2010. To estimate the number of PIV-associated hospitalizations that occurred annually among U.S. children aged <5 years from 1998 through 2010, respiratory hospitalizations from the Healthcare Cost and Utilization Project Nationwide Inpatient Sample were multiplied by the proportion of acute respiratory infection hospitalizations positive for PIV among young children enrolled in the New Vaccine Surveillance Network. Estimates of hospitalization charges attributable to PIV infection were also calculated., Results: Parainfluenza virus seasonality follows type-specific seasonal patterns, with PIV-1 circulating in odd-numbered years and PIV-2 and -3 circulating annually. The average annual estimates of PIV-associated bronchiolitis, croup, and pneumonia hospitalizations among children aged <5 years in the United States were 3888 (0.2 hospitalizations per 1000), 8481 per year (0.4 per 1000 children), and 10,186 (0.5 per 1000 children), respectively. Annual charges for PIV-associated bronchiolitis, croup, and pneumonia hospitalizations were approximately $43 million, $58 million, and $158 million, respectively., Conclusions: The majority of PIV-associated hospitalizations in young children occur among those aged 0 to 2 years. When vaccines for PIV become available, immunization would be most effective if realized within the first year of life., (Published by Oxford University Press on behalf of the Pediatric Infectious Diseases Society 2014. This work is written by (a) US Government employee(s) and is in the public domain in the US.)

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.

We examined if croup presentations to the emergency department (ED) were associated with weather changes in a warm temperate climate. We collected data on all 729 cases with an ED discharge or admission diagnosis of croup over a 798 day time period. We obtained detailed climatic records from the New South Wales Meteorological Office for the same time period. Only one daily variable, ground temperature at 9:00, was significantly associated with the number of croup attendances (linear regression -0.2062; 95% CI -0.272 to -0.138). There was a stronger correlation (-0.426; 95% CI -0.684 to -0.072) between the calculated mean monthly temperature and the monthly number of croup admissions. Even in this milder climate, croup is associated with cooler weather. We are unable to conclude that hospital attendances for croup are caused by changes in temperature alone, as other factors such as the prevalence of viral illness also follow a seasonal, and therefore, temperature-related pattern.

In the incidence patterns of cholera, diphtheria and croup during the past when they were of epidemic proportions, we document a set of cycles (periods), one of which was reported and discussed by A. L. Chizhevsky in the same data with emphasis on the mirroring in human disease of the ~11-year sunspot cycle. The data in this study are based on Chizhevsky’s book The Terrestrial Echo of Solar Storms and on records from the World Health Organization. For meta-analysis, we used the extended linear and nonlinear cosinor. We found a geographically selective assortment of various cycles characterizing the epidemiology of infections, which is the documented novel topic of this paper, complementing the earlier finding in the 21st century or shortly before, of a geographically selective assortment of cycles characterizing human sudden cardiac death. Solar effects, if any, interact with geophysical processes in contributing to this assortment.

Background: Prospective data on viral etiology and clinical characteristics of bronchiolitis and upper respiratory illness (URI) in infants are limited., Methods: This prospective cohort enrolled previously healthy term infants during inpatient or outpatient visits for acute URI or bronchiolitis during September to May 2004 to 2008. Illness severity was determined using an ordinal bronchiolitis severity score. Common respiratory viruses were identified by real-time reverse-transcriptase polymerase chain reaction., Results: Of 648 infants, 67% were enrolled during inpatient visits and 33% during outpatient visits. Seventy percent had bronchiolitis, 3% croup and 27% URI. Among infants with bronchiolitis, 76% had respiratory syncytial virus (RSV), 18% human rhinovirus (HRV), 10% influenza, 2% coronavirus, 3% human metapneumovirus and 1% parainfluenza virus. Among infants with croup, 39% had HRV, 28% parainfluenza virus, 28% RSV, 11% influenza, 6% coronavirus and none human metapneumovirus. Among infants with URI, 46% had HRV, 14% RSV, 12% influenza, 7% coronavirus, 6% parainfluenza virus and 4% human metapneumovirus. Individual viruses exhibited distinct seasonal, demographic and clinical expression., Conclusions: The most common infections among infants seeking care in unscheduled medical visits for URI or bronchiolitis were RSV and HRV. Demographic differences were observed between patients with different viruses, suggesting that host and viral factors play a role in phenotypic expression of viral illness.

Objectives: The objectives were (1) to determine trends in radiograph use in emergency department (ED) care of children with asthma, bronchiolitis, and croup; and (2) to examine the association of patient and hospital factors with variation in radiograph use., Methods: A retrospective, cross-sectional study of National Hospital Ambulatory Medical Care Survey data between 1995 and 2009 on radiograph use at ED visits in children aged 2 to 18 years with asthma, aged 3 months to 1 year with bronchiolitis, and aged 3 months to 6 years with croup. Odds ratios (ORs) were calculated and adjusted for all factors studied., Results: The use of radiographs for asthma increased significantly over time (OR: 1.06; 95% confidence interval [CI]: 1.03-1.09; P < .001 for trend) but were unchanged for bronchiolitis and croup. Pediatric-focused EDs had lower use for asthma (OR: 0.44; 95% CI: 0.29-0.68), bronchiolitis (OR: 0.37; 95% CI: 0.23-0.59), and croup (OR: 0.34; 95% CI: 0.17-0.68). Compared with the Northeast region, the Midwest and South had statistically higher use of radiographs for all 3 conditions. The Western region had higher use only for asthma (OR: 1.67; 95% CI: 1.07-2.60), and bronchiolitis (OR: 2.94; 95% CI: 1.48-5.87). No associations were seen for metropolitan statistical area or hospital ownership status., Conclusions: The ED use of radiographs for children with asthma increased significantly from 1995 to 2009. Reversing this trend could result in substantial cost savings and reduced radiation. Pediatric-focused EDs used significantly fewer radiographs for asthma, bronchiolitis, and croup. The translation of practices from pediatric-focused EDs to all EDs could improve performance.

Objective: The aim of the study was to assess the effect of environmental pollution and parental tobacco smoking on the occurrence of pseudocroup in children., Material and Methods: A questionnaire-study was performed in 345 children with pseudocroup admitted to the ENT Dept between 1997-2007. 116 children had smoking and 229 had non-smoking parents. Both groups were compared with respect to environmental pollution (urban, rural), parents' level of education, household crowding and breast feeding period. The prevalence of upper and lower respiratory tract infections and the presence of allergy were also anlaysed. The results were compared to those performed in the ENT Dept in 1977-1986., Results: In the group of rural children, 21 were children with pseudocroup from smoking parents and 36 children of non-smoking parents. Among children living in the urban areas there were 95 from smoking parents and 193 from non-smoking parents. Both non-smoking parents presented a large group of people with a higher level of education, and in the smoking families both parents presented a lower level of education. Analysis of the breast feeding period revealed that it was the longest (up to 9 months) in non-smoking mothers--21% of the group, and only in 4.3% of smoking mothers.

Objectives: The objective of this study was to investigate whether different staffing models are associated with variation in radiograph use for children seen for bronchiolitis, croup, and asthma and discharged home from emergency departments (EDs) in Ontario., Methods: We surveyed all Ontario EDs regarding physician staffing models and use of clinical protocols. We used a population-based ED database to determine radiograph rates and patient characteristics. Regression techniques that controlled for patient factors and clustering within EDs were applied., Results: From April 2004 to March 2006, 5,186, 10,408, and 35,150 children were discharged home from an ED with bronchiolitis, croup, and asthma, respectively. Radiograph rates were 42.7% for bronchiolitis, 10.1% for croup, and 25.9% for asthma. Over 50% of children were treated in EDs with nonpediatric front-line care but with consultant pediatricians available. Compared to children in these settings, those seen in EDs with front-line pediatric staff were less likely to have radiographs for all three conditions (adjusted odds ratios [ORs] 0.47 [95% CI 0.24-0.95], 0.47 [95% CI 0.27-0.82], 0.13 [95% CI 0.02-0.66] for bronchiolitis, croup, and asthma, respectively). Children in community hospitals with pediatricians were significantly more likely to have a radiograph if seen by a consultant pediatrician (OR 1.40, 95% CI 1.20-1.63 [bronchiolitis]; OR 2.76, 95% CI 2.16-3.53 [croup]; and OR 1.97, 95% CI 1.64-2.36 [asthma]). We found no association between clinical protocol use and radiograph rates., Conclusions: High rates of discretionary radiograph use exist for common respiratory problems of children seen across ED settings. Quality improvement efforts should be focused in this area, and radiograph use in EDs staffed by front-line pediatrics-trained staff could serve as an initial benchmark target for other institutions.

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., (Copyright © 2011 by Lippincott Williams & Wilkins)

Background: Human coronavirus NL63 (HCoV-NL63) has recently been implicated as a common cause of croup in children. This study was performed to evaluate viruses associated with croup in children, with an emphasis on HCoV-NL63., Methods: Nasopharyngeal aspirates were prospectively collected from 182 children hospitalized with croup at Seoul National University Bundang Hospital from January 2005 to June 2009. Multiplex reverse-transcriptase polymerase chain reaction was conducted for detection of 11 respiratory viruses, and medical records were reviewed., Results: Viruses were identified in 147 (80.8%) of the 182 croup patients. The 3 most commonly detected viruses were parainfluenza virus type 1 (PIV1) in 44 (24.2%) patients, HCoV-NL63 in 30 (16.5%) patients, and influenza A virus in 25 (13.7%) patients. Other detected viruses were rhinovirus in 22 (12.1%) patients, PIV type 3 and respiratory syncytial virus in 15 (8.2%) patients, human bocavirus in 8 (4.4%) patients, and several others in a few patients. Coinfections with > or = 2 viruses were found in 20 (11%) patients. HCoV-NL63 was identified primarily in winter, which coincides with the peak occurrence of croup. Patients with HCoV-NL63 infection were younger than those who were positive for PIV1 (median age 13 months versus 21 months, P = 0.006) and had shorter fever duration than influenza A virus infection (median 1.5 days versus 4 days, P = 0.000)., Conclusions: PIV1 and HCoV-NL63 were most commonly associated with patients who were hospitalized with croup. HCoV-NL63 is prevalent in winter and is associated with younger age and with shorter fever duration.

In this analysis we used BEACH (Bettering the Evaluation and Care of Health) encounters with children aged 0-14 years from January 2008 to December 2009. Croup was managed 276 times during that period (at 1.2% of 23 016 encounters with children in this age group). This suggests that croup is managed in general practice about 154,000 times per year nationally.

Purpose: The prevalence of asthma symptoms among preschool children is difficult to determine with accuracy because no gold standard is available for diagnosis. The aim of this study was to compare parent-reported wheezing or shortness of breath among infants as assessed by questionnaire and physician-interview., Methods: We studied 1,202 children participating in the Generation R study. Their parents completed a written questionnaire at home when the infant was 12 months old, including items on wheezing or shortness of breath. During the regular free-of-charge youth healthcare visit at age 14 months, the physician interviewed the parents to assess the presence of wheezing or shortness of breath., Results: The prevalence of wheezing or shortness of breath estimated from questionnaire was significantly higher than from physician-interview (36% vs. 20%; P < 0.001): observed agreement 73% (kappa 0.36). Only 41% of questionnaire-reported symptoms were assessed through the physician-interview, while 73% of physician-interviewed symptoms were reported in the questionnaire. Compared with infants in the subgroup with agreement on the presence of wheezing or shortness of breath, the infants in the subgroups without agreement significantly less often received anti-asthma medication and significantly less often had abnormal respiratory sounds or bronchiolitis or croup, and their mothers were significantly less often working. The proportion of infants receiving anti-asthma medication was higher in interview-data compared with questionnaire-data (22.7% vs. 3.9%; P < 0.001)., Conclusions: Questionnaire yielded higher prevalence rates for wheezing or shortness of breath than physician-interview. Physician-reported symptoms are associated with a higher proportion of infants receiving anti-asthma medication. Parent-reported asthma symptoms should be confirmed by pediatricians whenever possible.

Background: Croup is a common pediatric respiratory illness. While croup is generally a mild disease, exacerbations may be seen in the Emergency Department (ED) setting. The objective of this study was to describe the epidemiology of croup presentations to EDs made by infants (

Background: Croup, which is seen commonly in childhood, is a disorder that can be recurrent and progress to bronchial asthma. In the present study the prevalence of gastroesophageal reflux (GER) and atopy and the response to therapy were investigated in children with recurrent croup., Methods: Between October 2003 and June 2004, 57 patients with acute stridor were admitted to the emergency room. The patients who had at least three croup episodes and patients with first croup episode were compared., Results: Thirty-two children had recurrent croup history, GER was found in of 62.5%, and atopy in 17.2%. Atopy was not found in any children with first croup episode. The difference was significant. In addition it was found that atopic dermatitis, previous history of wheezing and established atopy increased the risk of croup recurrence. Alone or combined inhaled corticosteroids and GER therapy were administered, and 77.7% of the patients responded very well., Conclusion: GER and atopy should be investigated in patients with recurrent spasmodic croup. Recurrent croup is a non-specific manifestation of atopy. Patients with atopy should be followed closely for developing bronchial asthma.

Objective: To determine the population-based inpatient disease burden of parainfluenza virus in children <5 years of age., Study Design: The New Vaccine Surveillance Network (NVSN) enrolled children <5 years of age who were hospitalized with febrile or acute respiratory illnesses. Surveillance hospitals admitted >95% of all hospitalized children from each county. Combined nasal turbinate/throat swabs were tested for parainfluenza virus (PIV), respiratory syncytial virus, and influenza virus with culture and reverse-transcription-polymerase chain reaction. Both parental interviews and medical chart reviews were conducted. Age-specific population-based hospitalization rates were calculated., Results: From October 2000 through September 2004, 2798 children were enrolled. A total of 191 PIVs were identified from 189 children (6.8% of enrolled: 73 PIV type 1, 23 PIV type 2, and 95 PIV type 3), compared with 521 respiratory syncytial viruses and 159 influenza viruses. Mean PIV hospitalization rates were 3.01, 1.73, 1.53, 0.39, and 1.02 per 1000 children per year for ages 0 to 5 months, 6 to 11 months, 12 to 23 months, 24 to 59 months, and 0 to 59 months, respectively., Conclusions: PIV accounted for 6.8% of all hospitalizations for fever, acute respiratory illnesses, or both in children <5 years of age. The pediatric PIV inpatient burden is substantial and highlights the need to find an effective vaccine candidate.

Background: The incidence of childhood empyema, a complication of pneumonia, is increasing, and the underlying mechanisms are not understood. Whether a rise in pneumonia incidence could account for the increase in empyema remains to be seen., Objective: To report trends for empyema admissions in the context of pneumonia and croup admissions in Scottish children over a 25-year period to 2005., Design: Whole-population study with retrospective analysis using diagnosis codes (International classification of diseases, 9th and 10th revisions)., Setting: All non-obstetric and non-psychiatric hospitals in Scotland., Participants: Patients <15 years admitted with a diagnosis of empyema, pneumonia or croup (the latter included for reference) between 1 January 1981 and 31 December 2005., Results: There were 217 admissions for empyema in children (76 1-4-year olds), 24,312 admissions for pneumonia (11,299 1-4-year olds), and 31 120 (20,332 1-4-year olds) for croup. Empyema admissions increased after 1998 from <10 per million children per annum to reach a peak of 37 per million in 2005. In the 1-4-year age group, empyema admissions rose in the late 1990s and 2000s from an average of 6.5 per million per year between 1981 and 1998 to 66 per million in 2005. Overall annual admission rates for pneumonia remained unchanged in most age groups. However, among 1-4-year olds, admissions rose steadily by an average of 50 per million per year between 1981 and 2005. Admission rates for croup in Scottish children (<15 years) remained stable over the preceding 25 years., Conclusions: This whole-population study shows that the incidence of childhood empyema has risen since 1998 and continues to rise independently of pneumonia. Croup admissions remained stable, suggesting that changes in coding or admission policies are not likely to explain the observed trends. The observations suggest that the rise in empyema is not related to an increase in pneumonia. Changes in bacterial pathogenicity and/or host susceptibility may be important.

Human coronavirus NL63 (HCoV-NL63) is a global respiratory tract pathogen; however, the epidemiology of this virus in subtropical area is not well known. To evaluate the epidemics and disease spectrum of HCoV-NL63 infection in children in Taiwan, we prospectively screened children admitted to the hospital with respiratory tract infection from May 2004 to April 2005. Every enrolled child had a nasopharyngeal aspirate (NPA) sample taken. Quantitative RT-PCR was used to detect 1b gene of HCoV-NL63. A total of 539 NPAs were collected. Seven (1.3%) were positive for HCoV-NL63. All cases were boys younger than 3 years of age and most cases occurred in autumn. Co-infection with other pathogens was observed in three cases. The most common symptoms/signs of HCoV-NL63 infection were cough, fever, and inspiratory stridor. HCoV-NL63 was the most common pathogen (14.7%) in children with croup and was the cause of three cases of croup in October. The odds ratio of croup in children infected with HCoV-NL63 was 43.4 (95% CI 8.1 approximately 233.1). In conclusion, HCoV-NL63 is an important respiratory tract pathogen as the main cause in children admitted to the hospital in Taiwan.

The management of paediatric airway emergencies is part of ENT practice. The most common conditions are acute viral laryngotracheobronchitis (croup), acute epiglottitis and bacterial tracheitis. Management of these conditions is significantly different and accurate diagnosis is crucial. We performed a retrospective analysis of all acute airway admissions to the paediatric intensive care unit (PICU) at the Royal Belfast Hospital for Sick Children from 1990 to 2003. The results showed a gradual decrease in the number of admissions due to croup. Acute epiglottitis admissions decreased markedly after 1992 but rose again in 2000, with a peak in 2002. Bacterial tracheitis is now the most common paediatric airway emergency requiring PICU admission and its incidence has been steadily increasing since 1990, peaking in 2003. The total number of admissions showed little change over the 14-year period audited. The significant shift in the nature of these conditions and these findings confirm the ongoing requirement for caution in dealing with a suspected airway emergency.

Aim: To examine seasonal variation in hospital use for five paediatric conditions of the Australian Capital Territory residents., Methods: Hospital admissions (1993-2004) and emergency room (ER) presentations (1999-2004) for asthma, croup, bronchiolitis, other respiratory conditions and diarrhoea of children aged <5 years were compared by month and season., Results: The five conditions comprised 14% of admissions and 24% of ER presentations of children aged <5 years. Bronchiolitis (both admissions and ER presentations) were the highest in the 0-1 year age group (>80%) and the other four conditions peaked at 1-2 years. Children aged 0-2 years contributed 66% of diarrhoea, 62% of croup and 44% of other respiratory admissions whereas ER presentations were higher for other respiratory conditions (57%) and lower for croup (47%). Boys showed higher rates of admissions and ER presentations for all conditions except diarrhoea. Strong seasonal associations were apparent. Incident rate ratios of admissions were significantly higher in autumn compared with summer for asthma and croup whereas bronchiolitis and other respiratory conditions admissions were the highest in winter. Diarrhoea admissions were the highest in spring. ER presentations of the five conditions also showed similar associations with season., Conclusion: Hospital admissions and ER presentations of these five conditions showed strong seasonal patterns, knowledge of which could contribute to improved resource planning (staffing) to meet expected increases in demand for services and scheduling of elective admissions. These findings could be extended to develop a model for forecasting hospital use and to explore the causes of these diseases to ameliorate seasonal effects.

Asthma-related hospitalizations are sentinel events in pediatric asthma surveillance. Little is known about hospitalizations that are assigned a secondary discharge diagnosis of asthma (SDDA). The National Hospital Discharge Survey (NHDS) was analyzed to compare hospitalizations with primary versus secondary discharge diagnoses of asthma. Most hospitalizations with SDDA had primary diagnoses of respiratory origin. Surveillance systems tracking the hospitalization burden of pediatric asthma should consider including selected hospitalizations with a secondary diagnosis of asthma.

Human bocavirus was detected by PCR in 65 (5.1%) of 1,265 respiratory specimens collected in 2002 and 2003 from the Stollery Children's Hospital from children <17 years of age. The spectrum of illness included upper respiratory infection, croup, bronchiolitis, and pneumonia with a prominence of cough and fever.

Co-circulation of respiratory syncytial virus (RSV) and influenza has made the partitioning of morbidity and mortality from each virus difficult. Given the interaction between chronic obstructive lung disease (COPD) and pneumonia, often one can be mistaken for the other. Multivariate time-series methodology was applied to examine the impact of RSV and influenza on hospital admissions for bronchiolitis, pneumonia, and COPD. The Granger Causality Test, used to determine the causal relationship among series, showed that COPD and pneumonia are not influenced by RSV (P=0.2999 and 0.7725), but RSV does influence bronchiolitis (P=0.0001). Influenza was found to influence COPD, pneumonia, and bronchiolitis (P<0.0001). The use of multivariate time series and Granger causality applied to epidemiological data clearly illustrates the significant contribution of influenza and RSV to morbidity in the population.

Objective: As a consequence of evolving medical practice, the epidemiology of potentially life-threatening upper airway infections is changing. We report our experience over 9 years with viral croup, epiglottitis, and bacterial tracheitis., Patients and Methods: We studied a retrospective case series of patients admitted to Vermont Children's Hospital with potentially life-threatening upper airway infections viral croup, epiglottitis, or bacterial tracheitis between 1997 and 2006., Measurement and Main Results: There were 107 patients with viral croup admitted to Vermont Children's Hospital, with 16 (15%) admitted to the pediatric intensive care unit. Three patients with croup (17% of pediatric intensive care unit admissions, 3% of total admissions) required intubation. There were no serious complications. Eighteen patients were admitted with bacterial tracheitis. Ninety-four percent (n = 17) were admitted to the pediatric intensive care unit. Eighty-three percent (n = 15) were intubated. Twenty-eight percent of patients (n = 5) developed serious complications. Two adolescent patients were admitted with epiglottitis. Both were intubated and recovered without complications. Of 35 patients admitted to the pediatric intensive care unit with these potentially life-threatening upper airway infections, 20 patients (57%) developed respiratory failure. Fifteen patients (75%) had bacterial tracheitis, 3 patients (15%) had viral croup, and 2 patients (10%) had nonclassic epiglottitis., Conclusions: Immunization against Haemophilus influenza type b and widespread use of corticosteroids for the treatment of viral croup have changed the epidemiology of acute infectious upper airway disease. As potentially life-threatening infections, viral croup and epiglottitis have been eclipsed by bacterial tracheitis. In this series, bacterial tracheitis was 3 times more likely to have caused respiratory failure than viral croup and epiglottitis combined. Bacterial tracheitis should be considered in children who present with acute life-threatening upper airway infection.

Background: Croup is a term that groups several different clinical syndromes with inspiratory stridor. The failure to delineate the specific syndromes has led to suboptimal treatment in many instances., Methods: A literature review and personal experience have been analyzed., Results: Specific croup syndromes have been identified. Most croup steroid-treatment studies have failed to adequately identify the specific illness being treated. With 2 exceptions, all studies done to date have been too small to sufficiently evaluate risks of steroids if the risk is 1% or less., Conclusions: Three conclusions were reached: (1) no steroid treatment studies of moderate or severe laryngotracheitis have been of adequate size to determine the risk of progressive viral infection or secondary bacterial infection; (2) single dose steroid treatment or limited nebulized use is probably safe; and (3) we should encourage better clinical diagnosis of croup illnesses.

The presence of antibodies against human parainfluenza viruses type 2 and 3 was studied in 1 793 sera from an infantile population under 14 years old. The hemagglutination inhibition technique was used for screening the clinical samples. Of the total of analyzed sera, 1 382 (77.1%) were positive. The presence of antibodies against type 2 was confirmed in 320 of them (17.8%), and against type 3 in 334 (18.6%). The simultaneous seropositivity predominated in 805 (44.9%). The circulation of human parainfluenza viruses was corroborated during all the months of the year and in all the analyzed age groups. It was observed an increase in the positivity percentages with age.