Factors predicting hospitalization of pediatric patients with croup presenting to the emergency department: a retrospective cross-sectional study

Croup is the most common cause of acute, acquired upper airway obstruction in pediatric patients. Severe upper airway obstruction in children can quickly progress to respiratory failure; early and accurate diagnosis and treatment are essential. We examined the characteristics of pediatric patients with croup who visited our emergency department and required hospitalization even after appropriate treatment. We retrospectively studied patients who visited the pediatric emergency department of a tertiary hospital in Gyeonggi-do, Korea, from January 2018 to December 2021. After diagnosis and treatment using a defined protocol, all patients were divided into two groups: those who were hospitalized because they did not meet the criteria for discharge, and those who returned home. A multivariate logistic regression analysis was performed to identify factors associated with hospitalization. We studied 212 patients with an average age of 14 (12–16) months; 68 (32.0%) patients were female and 144 (67.9%) were male. In total, 47 (22.1%) patients were admitted for additional treatment. The multivariate logistic regression analysis revealed that tachycardia, tachypnea, decreased urine output and chest retraction were associated with hospitalization. A nomogram was constructed. Tachycardia, tachypnea, decreased urine volume and chest retraction in pediatric patients with croup showed a relationship with upper airway obstruction that persisted after treatment. If any of the above symptoms are observed in the emergency department, close observation is needed to determine whether respiratory failure is progressing; if so, prompt treatment is required.

Croup; Tachypnea; Tachycardia; Decreased urine output; Chest retraction

[1] Bjornson CL, Johnson DW. Croup in children. Canadian Medical Association Journal. 2013; 185: 1317–1323.

[2] Alqahtani AA, Masud N, Algazlan MS, Alqarni SS, Almutairi KN, Bahumiad AA, et al. The outcome of immediate administration of dexamethasone in children with croup (laryngotracheobronchitis) in king abdullah specialized children’s hospital. Cureus. 2022; 14: e25726.

[3] Sizar O, Carr B. Croup. StatPearls: Treasure Island. 2023.

[4] Quraishi H, Lee DJ. Recurrent croup. Pediatric Clinics of North America. 2022; 69: 319–328.

[5] Garzon Mora N, Jaramillo AP, Briones Andriuoli R, Torres S, Revilla JC, Moncada D. An overview of the effectiveness of corticoids in croup: a systematic literature review. Cureus. 2023; 15: e46317.

[6] Kashiura M, Amagasa S, Moriya T. The steeple sign of croup in an adult. Internal Medicine. 2022; 61: 2825.

[7] Argebesola A, Tam CM, Kothari A, Le ML, Ragheb M, Klassen TP. Glucocorticoids for croup in children. Cochrane Database of Systematic Reviews. 2023; 1: CD001955.

[8] Zoorob R, Sidani M, Murray J. Croup: an overview. American Family Physician. 2011; 83: 1067–1073.

[9] Hester G, Nickel AJ, Watson D, Maalouli W, Bergmann KR. Use of a clinical guideline and orderset to reduce hospital admissions for croup. Pediatrics. 2022; 150: e2021053507.

[10] Gates A, Gates M, Vandermeer B, Johnson C, Hartling L, Johnson DW, et al. Glucocorticoids for croup in children. Cochrane Database of Systematic Reviews. 2018; 8: CD001955.

[11] Olszanecka-Glinianowicz M, Chudek J, Urcus A, Almgren Rachtan A. Factors affecting the choice of budesonide in the therapy of croup, asthma and chronic obstructive pulmonary disease. Postepy Dermatologii I Alergologii. 2022; 39: 893–901.

[12] Meckler GD, Alqurashi W, Eltorki M, Curtis SJ, Doyle E, Kam AJ, et al. Epinephrine metered‐dose inhaler for pediatric croup. Academic Emergency Medicine. 2023; 30: 144–146.

[13] Walsh PS, Lipshaw MJ. Diurnal variation in frequency and severity of croup in the emergency department. Hospital Pediatrics. 2022; 12: 907–913.

[14] Hanna J, Brauer PR, Morse E, Berson E, Mehra S. Epidemiological analysis of croup in the emergency department using two national datasets. International Journal of Pediatric Otorhinolaryngology. 2019; 126: 109641.

[15] Asmundsson AS, Arms J, Kaila R, Roback MG, Theiler C, Davey CS, et al. Hospital course of croup after emergency department management. Hospital Pediatrics. 2019; 9: 326–332.

[16] Wen SH, Lin L, Yu G, Xu CR, Zhang HL, Zheng YM. Pseudomembranous laryngotracheobronchitis due to coinfection with human bocavirus and mycoplasma pneumoniae: a case report. Translational Pediatrics. 2021; 10: 673–678.

[17] Tintinalli JE, Ma OJ, Yealy DM, Meckler GD, Stapczynski JS, Cline DM, et al. Tintinalli’s emergency medicine a comprehensive study guide. 9th edn. McGraw Hill: New York. 2019.

[18] Robert M. Kliegman JSG. Nelson textbook of pediatrics. 21st edn. Elsevier: Philadelphia. 2019.

[19] Goldstein B, Giroir B, Randolph A. International pediatric sepsis consensus conference: definitions for sepsis and organ dysfunction in pediatrics. Pediatric Critical Care Medicine. 2005; 6: 2–8.

[20] Al-Halhouli A, Albagdady A, Alawaki J, Abeeleh MA. Monitoring symptoms of infectious diseases: perspectives for printed wearable sensors. Micromachines. 2021; 12: 620.

[21] Chapman SM, Maconochie IK. Early warning scores in paediatrics: an overview. Archives of Disease in Childhood. 2019; 104: 395–399.

[22] Chan A, Langley J, LeBlanc J. Interobserver variability of croup scoring in clinical practice. Paediatrics & Child Health. 2001; 6: 347–351.

[23] Saguil A, Fargo MV. Acute respiratory distress syndrome: diagnosis and management. American Family Physician. 2020; 101: 730–738.

[24] Lan B, Dong X, Yang Q, Luo Y, Wen H, Chen Z, et al. Exosomal microRNAs: an emerging important regulator in acute lung injury. ACS Omega. 2023; 8: 35523–35537.

[25] Shein SL, Maddux AB, Klein MJ, Bhalla A, Briassoulis G, Dahmer MK, et al. Epidemiology and outcomes of critically ill children at risk for pediatric acute respiratory distress syndrome: a pediatric acute respiratory distress syndrome incidence and epidemiology study. Critical Care Medicine. 2022; 50: 363–374.

[26] Yang W, Lee J, Chen C, Chang Y, Wu H. Westley score and clinical factors in predicting the outcome of croup in the pediatric emergency department. Pediatric Pulmonology. 2017; 52: 1329–1334.

[27] Loberger JM, Jones RM, Phillips AS, Ruhlmann JA, Rahman AKMF, Ambalavanan N, et al. Pediatric ventilation liberation: evaluating the role of endotracheal secretions in an extubation readiness bundle. Pediatric Research. 2023; 93: 612–618.

[28] Virbalas J, Smith L. Upper airway obstruction. Pediatrics in Review. 2015; 36: 62–73.

[29] Maalouli W, Petersen A, Strutt J, Bergmann KR, Axelrod A, Lee G, et al. Prediction model for croup admission need. Hospital Pediatrics. 2022; 12: 711–718.

[30] Maalouli WM, Hodges JS. Croup admissions: can we shrink the elephant in the room? Pediatric Emergency Care. 2021; 37: e940–e943.