CME Review Article
Croup—Treatment Update
Candice Leigh Bjornson, MD,* and David W. Johnson, MDy
Key Words: Croup, epidemiology, diagnosis, epinephrine,
corticosteroids
TARGET AUDIENCE
Physicians, resident physicians, medical students,
nurse practitioners, and physician assistants who assess and
treat children with croup. Pediatric emergency physicians,
pediatricians, and family physicians will find the information
contained in this comprehensive review especially useful.
LEARNING OBJECTIVES
After completion of this article, the reader will be
able to:
1. Discuss the epidemiology of croup in the pediatric
population.
2. Identify the common etiological agents for croup, and
describe the pathophysiology resulting in typical symp-
toms of croup.
3. Recognize clinical features that support alternate diagno-
ses and the potential complications of croup.
4. Describe 4 levels of clinical severity of croup.
5. Discuss the role of laboratory and radiological inves-
tigations in a child with croup.
6. Know the indications for hospital admission in a child
with croup.
7. Discuss the role of nonpharmaceutical interventions in a
child with croup (mist, oxygen).
8. Discuss the role of epinephrine and corticosteroids in a
child with croup.
EPIDEMIOLOGY
Croup (laryngotracheobronchitis) is a common respi-
ratory illness of childhood, estimated to affect approximately
*Clinical Assistant Professor, Alberta Children’s Hospital/University of
Calgary, Canada and yAssociate Professor Departments of Pediatrics
and Pharmacology and Therapeutics, University of Calgary, Faculty
of Medicine, Alberta Children’s Hospital, Canada.
Drs. Bjornson and Johnson have disclosed that they have no significant
relationship with or financial interests in any commercial companies that
pertain to this educational activity.
Wolters Kluwer Health has identified and resolved all faculty conflicts of
interest regarding this educational activity.
Address correspondence and reprint requests to David W. Johnson, MD,
Departments of Pediatrics and Pharmacology and Therapeutics, Univer-
sity of Calgary, Faculty of Medicine, Alberta Children’s Hospital, Canada.
Copyright n 2005 by Lippincott Williams & Wilkins
ISSN: 0749-5161/05/2112-0863
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3% of children younger than 6 years annually.1 The clinical
picture is characterized by the abrupt onset of a distinctive
barky cough, which may be accompanied by stridor, hoarse
voice, and respiratory distress. Croup symptoms are often
preceded by nonspecific symptoms of cough, rhinorrhea, and
fever. Croup is most common in children between the ages of
6 months and 3 years, with a peak annual incidence in the
second year of life of nearly 5%.1 However, croup occurs in
children of all ages, including adolescents,1 and rarely in
adults.2 Boys are affected more often than girls, with an
overall male to female preponderance of 1.4:1.1 In North
America, the peak season for croup is late autumn, but cases
are recognized year-round, even during the summer.1 In odd-
numbered years, the number of children presenting during
the peak season is approximately 50% more than during
even-numbered years.3 Symptoms are almost always worse
at night and can fluctuate in severity depending on whether
the child is agitated or calm. Usually, croup symptoms show
improvement during the day, but may recur on the following
evening.4 Croup symptoms are generally short-lived, with
approximately 60% of children having resolution within 48
hours. However, a small proportion has symptoms that may
continue for up to 1 week.4
Hospitalization of children with croup is uncommon,
with fewer than 5% admitted.5 – 7 Furthermore, of those
children hospitalized, intubation is rare, on the order of 1%
to 3%,8 – 11 and mortality is extremely rare.8 – 13
PATHOPHYSIOLOGY
The characteristic symptoms of croup are due to upper
airway obstruction resulting from an acute upper airway
infection. Infection leads to inflammation and edema of the
laryngeal mucosa, followed by epithelial necrosis and shed-
ding.14,15 Resultant narrowing of the subglottic region results
in a barky cough, turbulent airflow and stridor, and chest wall
indrawing. Further narrowing can lead to asynchronous chest
and abdominal movement, fatigue, and eventually hypoxia,
hypercapnia, and respiratory failure.16,17
Croup is caused by a variety of viruses, most commonly
parainfluenza types 1 and 3.3 Others implicated include in-
fluenza A, influenza B, adenovirus, respiratory syncytial
virus, metapneumovirus, and Mycoplasma pneumoniae.1,18,19
PHYSICAL EXAMINATION
When evaluating a child with a history suggestive
of croup, features on physical examination which help to
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establish this diagnosis include a seal-like barky cough, a gest epiglottitis.42 Bulging soft tissue of the posterior pharynx
hoarse voice or cry, inspiratory stridor, and chest wall re- suggests retropharyngeal abscess.42 A ragged tracheal contour
tractions.14 With more severe respiratory distress, children or a membrane spanning the trachea suggests bacterial
are often agitated, but they should not drool nor appear toxic. tracheitis.29,35,42 – 44 However, radiographs can also be normal
Fever can occur, occasionally as high as 408C.20 With in- in children with these diagnoses.45 If radiographs are justified
creasing respiratory distress, heart rate increases, whereas res- by an atypical clinical picture, it is imperative that patients be
piratory rate initially increases then declines.16,17 Impending closely monitored during imaging by experienced personnel
respiratory failure includes a change in mental status such as with appropriate airway management equipment and skills
fatigue or lethargy, pallor or cyanosis, and decreasing stridor, because progression of airway obstruction can be rapid.
breath sounds, or chest wall retractions.16,17,21 – 28 Continuous pulse oximetry and cardiorespiratory mon-
itoring are indicated in those with more severe croup but are
not necessary in mild cases.40 Occasionally, children without
DIFFERENTIAL DIAGNOSES severe croup may have low oxygen saturation resulting from
Most children presenting with an acute onset of upper intrapulmonary involvement.46 – 48
airway obstruction with stridor and chest wall indrawing
have croup.4,7 However, when evaluating a child with croup, ASSESSMENT OF SEVERITY
clinicians must be vigilant for signs and symptoms sug-
gestive of an alternate diagnosis. Bacterial tracheitis is dif- We could not find definitions of clinical severity of
ficult to distinguish from croup and is postulated to be a croup that are either widely accepted or rigorously derived.
complication of croup in the form of a bacterial super- For this review, we have elected to use definitions derived by
infection after an acute viral respiratory infection.8,29 – 31 A a committee consisting of a range of specialists and sub-
number of bacterial pathogens have been identified, including specialists during the development of a clinical practice
group A streptococcus, Staphylococcus aureus, Moraxella guideline from Alberta Medical Association (Canada).40 The
catarrhalis, Streptococcus pneumoniae, and Haemophilus definitions of severity have been correlated with the Westley
influenzae.29,31 – 33 Anaerobic bacteria have also been impli- croup score,23 because it is the most widely used clinical
cated.34 A child with high fever, toxic appearance, and a poor score, with well-demonstrated validity and reliability.49,50
response to treatment with epinephrine suggests bacterial Children with croup can be broadly divided into 4 levels of
tracheitis.29,31,35,36 Management of bacterial tracheitis in-
cludes broad-spectrum intravenous antibiotics and close mon-
itoring of the airway, as many patients require intubation and TABLE 1. Croup Severity40
respiratory support during the initial stages of treatment. Corresponding
A second potential alternative diagnosis is epiglottitis. Level of Westley Croup
Epiglottitis is now rare since the introduction of Haemophilus Severity Characteristics core (0– 17)23
influenzae B vaccine, as the primary etiologic agent is
Mild Occasional barking cough 0–2
H. influenzae.37 – 39 A sudden onset of high fever, absence of
barky cough, drooling, dysphagia, anxiety, and a preference to None to limited stridor at rest
sit forward in a ‘‘sniffing position’’ suggest epiglottitis. If None to mild suprasternal and/or
epiglottitis is suspected, the most crucial aspect of treatment is intercostal indrawing (retractions
of the skin of the chest wall)
to secure the airway by a physician highly experienced in
airway management. Moderate Frequent barking cough 3–5
Other extremely rare causes of stridor to be considered Easily audible stridor at rest
in children presenting with more atypical croup symptoms Suprasternal and sternal wall
include foreign body aspiration in the upper airway or esoph- retraction at rest
agus, retropharyngeal or peritonsillar abscess, and hereditary Little to no distress or agitation
angioedema. Severe Frequent barking cough 6 – 11
Prominent inspiratory and
occasionally expiratory stridor
INVESTIGATIONS Marked sternal wall retractions
In a child presenting with the typical clinical features of Significant distress and agitation
croup, laboratory tests are usually unnecessary and should be Impending Barking cough (often not prominent) 12 – 17
deferred whenever possible if the patient is in respiratory respiratory Audible stridor at rest
distress.40 As viral cultures and rapid antigen tests do not aid failure (occasionally hard to hear)
in the routine acute management of children with croup, they
Sternal wall retractions
are not recommended.40 Likewise, radiological studies are (may not be marked)
not recommended in a child with a typical history and ap-
Lethargy or decreased level
propriate response to treatment.40 However, the anteroposte-
of consciousness)
rior and lateral soft tissue neck radiograph can be helpful in
Often dusky complexion without
supporting an alternative diagnosis in a child with atypical supplemental oxygen
disease.41 A thickened epiglottis and aryepiglottic folds sug-

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Pediatric Emergency Care  Volume 21, Number 12, December 2005
severity: mild, moderate, severe, and impending respiratory
failure (Table 1). Approximately 85% of children presenting
to general emergency departments have mild croup based
on this classification scheme, and less than 1% have severe
croup (unpublished prospective data obtained from 21 Alberta
general emergency departments). Although most children
have relatively mild symptoms, the sudden onset of croup
symptoms during the night causes parents to have sufficient
concern to bring their child to an emergency department.7,51
Consequently, it is important to educate parents about the self-
limited nature of the disease and provide clear careful advice
about when to seek reassessment.
GENERAL CARE
During assessment and treatment in the emergency
department, the child should be made as comfortable as
possible, and special care should be taken to avoid agitating
the child with unnecessary procedures. This is usually best
accomplished by having the child sit comfortably on the lap
of a parent or caregiver. Although there is no literature to
evaluate the effects of using oxygen in children with
moderate to severe croup, a randomized trial of oxygen
versus no oxygen would be considered unethical, and there is
widespread consensus that oxygen is beneficial for children
with respiratory distress.40,52 – 56 Accordingly, ‘‘blow-by’’
oxygen given via a plastic hose with the opening close to the
nose and mouth should be provided to children who are
showing signs of significant respiratory distress.
Children with croup have been treated with humidified
air for more than a hundred years, but there is no published
evidence to support its use.52,57 Two well-designed,
moderate-sized, placebo-controlled trial and 2 small studies
have not shown any improvement in clinical severity from
mist therapy.58 – 61 Furthermore, mist tents are potentially
harmful because they often cause children to be upset and
cry because tents are cold, wet, and separate the child from
their parents.62 A small case series reported scald injuries in
children with croup from hot humidified air.63 In addition, if
mist tents are improperly cleaned, they may disperse fungus
and molds into the environment.57 Consequently, mist wands,
bedside humidifiers, and mist tents are not recommended.40,64
Administration of a helium-oxygen mixture to children
with croup has been theorized to be beneficial because of the
potential of the lower density helium gas (compared with
nitrogen) to decrease airflow turbulence through a narrow
airway. In experienced hands, heliox may have some benefit
in children with very severe respiratory distress; however,
there is currently insufficient evidence to recommend its
general use in children with severe croup.65 – 72
PHARMACOTHERAPY
Analgesics and Antipyretics
No controlled trials have been published examining
the use of analgesics or antipyretics in children with croup.
However, it is reasonable to suggest their use for the
benefit of reduction of fever or discomfort in children with
croup.40,52 – 56
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Croup—Treatment Update
Antitussives and Decongestants
Similarly, no controlled trials have been published
addressing the potential benefits of antitussive or deconges-
tant medications in children with croup. Because there is no
rational physiological basis for their use, they should not be
administered to children with croup.40,52 – 56
Antibiotics
As most of croup has a viral etiology, empiric
antibiotic treatment is not logical. We found no randomized
controlled trials or prospective cohort studies evaluating
antibiotics in children with croup. Although ‘‘superinfec-
tions,’’ such as bacterial tracheitis and pneumonia, do occur;
the frequency is so rare (<1/1000 cases of croup) that the use
of antibiotics as prophylaxis against these rare occurrences is
not recommended.40,52 – 56
Short-Acting (Nebulized) b2-Agonists
We found no systematic review, randomized clinical
trials, or observational studies assessing the effects of neb-
ulized short-acting b2-agonists in children with croup.
Given the pathophysiology of croup, there is no clear theo-
retical reason to use short-acting b2-agonists for treatment
of croup.40,52 – 56
Epinephrine
The use of nebulized epinephrine has been well studied
and has a long history of use in children with croup. The
administration of epinephrine in children with severe croup
has been reported—using historical comparisons—to sub-
stantially reduce the number of children requiring intubation
or tracheotomy.73 Three randomized controlled trials have
found that nebulized racemic epinephrine (2.25%), compared
with placebo, improved croup scores within 10 to 30 minutes
of initiating treatment.74 – 76 A fourth placebo-controlled trial
did not show clear benefit; however, this trial was neither
well designed nor well reported.77 Five prospective cohort
studies using objective pathophysiological measures of sev-
erity have also shown significant improvement after epi-
nephrine treatment.24,61,78 – 80 In general, clinical effect is
sustained for at least 1 hour22 – 24,77 – 79,81 but is essentially
gone within 2 hours of administration.23 It is important to
note that, as epinephrine therapy wears off, patient’s symp-
toms return, on average, to their baseline severity, and few
develop clinical severity that is worse than before treatment
(the so-called ‘‘rebound effect’’).23,76 Combined results from
5 prospective clinical trials in outpatients treated with
epinephrine and dexamethasone (or budesonide) and ob-
served for between 2 and 4 hours, found that 12 (5%, 95%
confidence interval [CI] 2% – 7%) of 253 children discharged
home returned for care within 48 to 72 hours; 6 (2%, upper
95% CI <4%) of these were admitted to hospital, and none
had adverse outcomes.82 – 86 This prospectively derived data
along with 2 retrospective cohort studies provide good
evidence that children who are treated with epinephrine can
be safely discharged home, provided that their symptoms
have not recurred within 2 to 4 hours after treatment.87,88
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Published randomized controlled trials of children
administering 1 dose of nebulized epinephrine at a time have
not reported any adverse effects or a clinically significant
increase in either heart rate or blood pressure.22,65,76,81,89
Although clinical experience suggests that ‘‘back-to-back’’
doses of epinephrine may be used in cases of impending res-
piratory failure, a case report of a previously healthy child with
severe croup who developed ventricular tachycardia and
myocardial infarction (documented by persistently abnor-
mal electrocardiogram, elevated creatine phosphokinase –
myocardial band levels, and an abnormal nuclear stress test)
after treatment with 3 nebulizations of epinephrine within a
1-hour time span suggests that repeated doses of epineph-
rine should only be used with caution.90
Traditionally, racemic epinephrine has been used to
treat children with croup. However, epinephrine 1:1000 is as
effective and safe as the racemate form, as demonstrated in a
randomized trial in 31 children aged 6 months to 6 years with
moderate to severe croup.89 Most published studies have
used the same dose in all children regardless of size (0.5 mL
of 2.25% racemic epinephrine or 5.0 mL of epinephrine
1:1000). This approach is supported by data derived from the
treatment of lower airway disease with aerosolized medi-
cations, which suggests that the dose of drug actually de-
livered to the upper airway is modulated by each child’s
relative tidal volume.91 – 94
Corticosteroids
The use of corticosteroids to treat croup is supported
by numerous well-designed clinical trials and systematic
reviews, with clear benefits, relative to placebo, regardless of
clinical severity.52,95 – 99 In children with severe croup and
impending respiratory failure, a systematic review found
that, compared with placebo, corticosteroid treatment sig-
nificantly reduced the rate of endotracheal intubation
(9 studies involving 1126 children; rate of intubation 1/575
[0.2%] for corticosteroid vs. 7/551 [1.3%] for placebo;
absolute risk reduction 1.1% with 95% CI 0.1% – 2.1%).98
This review included studies of different types of corti-
costeroids and routes of administration (dexamethasone
[intramuscular, oral, or subcutaneous], methylprednisolone
[intramuscular], and prednisolone [oral]). A subsequent ran-
domized controlled trial in 70 children with croup who were
intubated compared placebo with prednisolone (1 mg/kg
via nasogastric tube every 12 hours until extubation).100
Prednisolone treatment significantly reduced the duration of
intubation when compared with placebo (median duration 98
vs. 138 hours) and the need for reintubation (2/38 [5%] vs.
11/32 [34%]).100 Moreover, mandatory treatment of children
with croup evaluated in a tertiary hospital in western
Australia with corticosteroids decreased the average number
intubated from 10 to 2 per year.101
In children with moderate to severe croup, corticoste-
roid treatment is associated with improvement in Westley
clinical croup score23 severity at 6 hours (mean reduction
of 1.2 points) and 12 hours (mean reduction of 1.9
points), fewer return visits and/or readmissions (relative risk
0.50, 95% CI 0.36 – 0.70), reduced length of stay in emer-
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gency department or hospital (mean reduction 12 hours, 95%
CI 5 –19 hours), and reduction in use of epinephrine treat-
ment (risk difference 10%, 95% CI 1% –20%) as compared
with placebo.95
The benefits of corticosteroid treatment are also clear
for children with mild croup. A randomized controlled trial
of oral dexamethasone (0.15 mg/kg) versus placebo in 100
children with mild croup found a significant reduction in
return to medical care with ongoing croup symptoms when
compared with placebo (0/50 vs. 8/50).102 A recent multi-
center, randomized, placebo-controlled clinical trial involv-
ing 720 children with mild croup demonstrated that children
treated with dexamethasone, as compared with placebo, were
half as likely to return for medical care because of ongoing
croup symptoms (7% vs. 15%) and had significantly milder
croup symptoms and less lost sleep in the 48 hours after
treatment. An additional benefit was a reduction in the stress
perceived by caregivers related to their child’s croup illness in
the 24 hours after treatment. There were also small but
significant economic benefits to both the family and health
care system in the corticosteroid group, on average, a savings
of US$21 per child.103 These benefits were present regardless
of duration of croup symptoms before treatment and across the
range of ‘‘severity’’ in these children with mild croup.
Corticosteroids—Route of Administration
The optimal route of administration of corticosteroid
treatment has been examined by 5 randomized controlled
trials comparing inhaled versus parenteral (oral or intra-
muscular) administration.20,104 – 107 All studies demonstrated
either equivalence or superiority of the oral or intramuscular
route. In cases of persistent vomiting that limits oral intake,
however, inhaled budesonide offers an alternative to the
intramuscular injection of dexamethasone.
Two randomized controlled trials compared oral and
intramuscular dexamethasone. The first trial in 277 children
found no significant difference between the 2 routes
(dexamethasone 0.6 mg/kg oral vs. intramuscular) in reso-
lution of croup symptoms, return for medical care or re-
assessment, or admission to hospital.108 The second trial in
96 children found no significant difference between the 2
routes (dexamethasone 0.6 mg/kg oral vs. intramuscular) in
hospital admission, return for medical care within 24 hours
of treatment, or further treatment with corticosteroid or
epinephrine.109
The standard dose of dexamethasone is 0.6 mg/kg (oral
or intramuscular). Oral administration is preferable because
absorption is excellent and peak serum concentrations are
achieved as rapidly as with intramuscular injection.110,111
The large majority of children tolerate oral dexamethasone
well, with vomiting an unusual occurrence.99 Clinical ex-
perience suggests that improvement begins within 2 hours
after treatment.86
Corticosteroids—Dosing
A systematic review of 10 controlled trials involving
1286 children suggests that higher doses of corticosteroids
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Pediatric Emergency Care  Volume 21, Number 12, December 2005 Croup—Treatment Update

FIGURE 1. Croup in the out-patient setting.

are associated with clinically important improvements in 0.15 mg/kg in a total of 80 children with mild to moderate
a greater proportion of children.98 A single dose-ranging croup, and found no differences in the degree of clinical
study has been published, comparing doses of 0.6, 0.3, and improvement between the 3 treatment groups. However, the

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Bjornson and Johnson Pediatric Emergency Care  Volume 21, Number 12, December 2005
study was not designed to test equivalence, and it is unclear
whether the study was sufficiently powered to detect clin-
ically significant differences between the 3 groups.95,112
Currently, there are no controlled studies that examine
whether multiple doses of corticosteroids confer a greater
benefit than a single dose. Nonetheless, given the short course
of illness in the majority of children with croup, a single dose
is likely sufficient for most patients. In a large clinical trial of
720 children with mild croup, virtually all patients had
resolution of symptoms by day 3 after medical assessment,
regardless of whether they received dexamethasone or
placebo, and rebound worsening was not observed.103
Given the extensive evidence of benefit of corticoste-
roid treatment in children with mild, moderate, and severe
croup, all children should be treated, with the rare exception
of a child who has a known immunodeficiency or recent
exposure to varicella.113 – 119
Indications for Admission to Hospital and
Discharge From Medical Care
Although current practice suggests that most of children
with croup can be safely managed as outpatients, little evi-
dence has been published that clarifies precisely which chil-
dren should be admitted to hospital.40,120,121 Data from a
retrospective cohort of 527 children hospitalized in Royal
Children’s Hospital (Melbourne) for persistent stridor at rest
before the routine use of corticosteroids showed that children
with persistent sternal indrawing at presentation to an emer-
gency department had a 6% risk for endotrachael intubation,
whereas those without sternal and chest wall indrawing
recovered rapidly and spontaneously without any specific
therapy.121 Data from a placebo-controlled trial of cortico-
steroids suggest that observation in an emergency department
for at least 3 hours, and optimally up to 10 hours, after
treatment with corticosteroids before deciding to admit chil-
dren to hospital can half the rate of hospitalization.20 A clin-
ical pathway at the Children’s Hospital at Westmead (Sydney)
which mandates 6 hours of emergency department observa-
tion before patients can be admitted to a hospital has sub-
stantially decreased utilization rates. Patients who present
with stridor at rest and chest wall indrawing are treated with
dexamethasone and epinephrine and observed for 6 hours. At
this time, if patients continue to have stridor at rest, they are
admitted, otherwise they are discharged home. This has re-
duced the average length of stay in the emergency department/
hospital from 19 to 5 hours, the rate of hospital admission
from 53% to 18%, and the rate of intensive care admission
from 10% to 0% (prepathway = 157 and postpathway = 110
children). No children experienced an adverse outcome.120
Based on this evidence and expert opinion, the Alberta
Medical Association Clinical Pathway Committee has rec-
ommended the management algorithm outlined in Figure 1.
SUMMARY
Most children who present with an acute onset of barky
cough, stridor, and indrawing have croup. A careful history
and physical examination are the best tool to confirm the
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diagnosis of croup and to rule out potentially serious
alternative diagnoses such as bacterial tracheitis and other
rare causes of upper airway obstruction. Nebulized epineph-
rine is effective for the temporary relief of significant
symptoms of airway obstruction. Corticosteroids are the
mainstay of treatment, and benefit is seen in children with all
levels of severity of croup, including mild cases.
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Pediatric Emergency Care  Volume 21, Number 12, December 2005 Croup—Treatment Update

CME EXAM

Instructions for the Pediatric Emergency Care CME Program Examination

To earn CME credit, you must read the designated article and complete the examination below, answering at least 80%
of the questions correctly. Mail a photocopy of the completed answer sheet to the Office of Continuing Education, Wolters
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be mailed to each participant within six to eight weeks after WKH receipt. The answers for this examination will appear in the
March 2006 issue of Pediatric Emergency Care.
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Physician’s Recognition Award. Each physician should claim only those credits that he/she actually spent in the activity.
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continuing medical education for physicians.

CME EXAMINATION
December 2005

Please mark your answers on the ANSWER SHEET.

Croup—Treatment Update, Bjornson and Johnson

1. The most frequent etiology for croup is: and coarse breath sounds. The test you would be most
a) Influenza A likely to perform at this time is:
b) Parainfluenza a) Arterial blood gas
c) Haemophilus influenzae b) Venous blood gas
d) Influenza B c) Complete blood count
e) Metapneumovirus d) Rapid viral assay
2. The parents of a 2-year-old girl relate that their daughter e) Lateral neck x-ray
became ill with a fever and cough 3 days ago and that she 4. The treatment of croup that is most clearly evidence-based
has had trouble breathing for 24 hours. Her vital signs are is:
temperature 38.68C, pulse rate 165 beats per minute, a) Oxygen
blood pressure 95/50 mm Hg. On examination, you ob- b) Mist
serve perioral cyanosis, retractions, and diffuse rhonchi. c) Heliox
The most worrisome respiratory rate (in breaths per d) Antibiotics
minute) in this child would be: e) Epinephrine
a) 15 –20 5. Which of the following statements concerning corticoste-
b) 20 – 25 roid therapy for croup is most consistent with published
c) 25 –30 data:
d) 30 – 35 a) Corticosteroids are indicated only in cases of moderate
e) 35 –40 to severe illness.
3. A 14-month-old previously healthy boy presents with a 6- b) No randomized controlled trials have demonstrated the
hour history of stridor which began that morning. His efficacy of corticosteroids.
parents report a mild cough. Vital signs are temperature c) Intramuscular and oral corticosteroids are equally
37.88C, pulse rate 120 beats per minute, respiratory rate 28 efficacious.
breaths per minute, blood pressure 95/60 mm Hg, and d) Inhaled corticosteroids have no role in croup.
oxygen saturation 97%. On examination, you find that the e) Repeated dosing of corticosteroids is essential to
boy appears to be in mild distress, with stridor, retractions, achieve the optimum effect.

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Bjornson and Johnson Pediatric Emergency Care  Volume 21, Number 12, December 2005

ANSWER SHEET FOR THE PEDIATRIC EMERGENCY CARE

CME PROGRAM EXAM
December 2005
Please answer the questions on page 371 by filling in the appropriate circles on the answer sheet below. Please mark the one
best answer and fill in the circle until the letter is no longer visible. To process your exam, you must also provide the following
information:

Name (please print): ______________________________________________________________________________________

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City/State/Zip ___________________________________________________________________________________________

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1. A B C D E
2. A B C D E
3. A B C D E
4. A B C D E
5. A B C D E

Your evaluation of this CME activity will help guide future planning. Please respond to the following questions.
1. Did the content of the article(s) meet the stated learning objectives?
[ ] Yes [ ] No
2. On a scale of 1 to 5, with 5 being the highest, how do you rank the overall quality of this educational activity as it pertains to
your practice?
[]5 []4 []3 []2 []1
3. As a result of meeting the learning objectives of this educational activity, will you be changing your practice behavior in
a manner that improves your patient care? If yes, please explain.
[ ] Yes [ ] No
________________________________________________________________________________________________________
________________________________________________________________________________________________________
4. Did you perceive any evidence of bias for or against any comercial products? If so, please explain.
[ ] Yes [ ] No
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________________________________________________________________________________________________________
5. Please state one or two topics that you would like to see addressed in future issues.
6. How long did it take you to complete this CME activity?
__________hour(s) __________minutes

Must be Received by February 15, 2006 in the

Office of Continuing Education
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530 Walnut Street, 8th Floor East
Philadelphia, PA 19106

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Pediatric Emergency Care  Volume 21, Number 12, December 2005 Croup—Treatment Update

CME EXAM ANSWERS

Answers for the Pediatric Emergency Care CME Program Exam

Below you will find the answers to the examination covering the review article in the September 2005 issue. All participants
whose examinations were postmarked by November 15, 2005 and who achieved a score of 80% or greater will receive a
certificate from Wolters Kluwer Health.

EXAM ANSWERS
September 2005

1. A
2. E
3. C
4. B
5. E

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