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Laryngitis in Children

Essentials

Laryngitis, or inflammation of the larynx, is a viral infection most commonly causing barking cough and inspiratory stridor (wheezing).
Laryngitis most commonly occurs at the age of 6 to 36 months.
Most patients only have mild symptoms and can be treated at home.
Respiratory distress associated with laryngitis can be treated with an oral glucocorticoid. In addition, inhalable racemic adrenaline can be used in severe, acute cases.
Patients whose general condition is affected or whose respiratory distress is not alleviated by first-aid medication or recurs quickly after such medication should be assessed in specialized care.

Aetiology

Laryngitis is a viral infection.
Parainfluenza viruses are the most common causative agents.
Influenza viruses may cause laryngitis with symptoms more severe than usual.

Symptoms and findings

The symptoms of laryngitis include sudden-onset dry, hoarse, dull, ”barking” cough and, in more severe cases, loud or wheezy, laboured inspiration (stridor).
Respiratory distress in a child should be assessed clinically. Signs of respiratory distress usually include audible stridor and, additionally, use of auxiliary breathing muscles and increased respiratory rate.
Oxygenation should always be checked with a pulse oximeter if the child has breathing difficulties, and supplemental oxygen should be administered if necessary (oxygen saturation less than 95%).
- Even a mild disturbance in oxygenation detected in association with inspiratory difficulty may be a sign of incipient respiratory failure (ventilation disturbance).
The possibility of bacterial tracheitis, epiglottitis, a foreign body or, in infants in particular, structural anomalies, should be kept in mind if there is no response to first-aid medication or if the child is exceptionally ill.
Emergency laboratory tests or x-rays are not needed in uncomplicated laryngitis.

Treatment Glucocorticoids for Acute Laryngotracheitis in Children, Nebulised Adrenaline for Croup in Children, Humidified Air Inhalation for Viral Croup

Typical laryngitis with no respiratory distress will resolve spontaneously.
In home care, cool air may be beneficial in alleviating the symptoms: the child should be taken in an upright position, carried by one of the parents, to an open window or outdoors. If there is respiratory distress, however, the child should be assessed by a physician.
There is no scientific evidence on the efficacy of vapour breathing.
Respiratory distress associated with laryngitis can be treated with an oral glucocorticoid. In severe, acute cases, inhalable racemic adrenaline can be used additionally; see Table T1.
A single oral dose of a glucocorticoid will help to alleviate respiratory distress associated with laryngitis and prevent particularly effectively the recurrence of respiratory distress. See Table T1.
- The dose of dexamethasone is 0.15-0.6 mg/kg orally or intramuscularly (maximum dose 8 mg).
- The dose of betamethasone (may require special permit) is 0.25-0.4 mg/kg orally (maximum dose 7 mg). A 0.5 mg tablet dissolved in liquid tastes better than dexamethasone.
If respiratory distress persists despite oral administration of a glucocorticoid, 2 mg of inhalable budesonide can be given additionally, usually at a hospital.
In severe inspiratory difficulty, inhalable racemic adrenaline can be given as first aid; see Table T1. Racemic adrenaline effectively alleviates the symptoms of respiratory distress due to laryngitis but it is short-acting, 1-2 hours only.
- Because the respiratory difficulty often recurs after 1-2 hours, patients who have been given racemic adrenaline should be referred without hesitation to hospital after first aid or followed up at the office for long enough (no less than 1-2 hours).

Pharmacotherapy of laryngitis

Glucocorticoid
A single dose of 0.25-0.4 mg/kg/day (maximum dose 7 mg) betamethasone tablets dissolved in water and taken orally or a single oral dose of 0.15-0.6 mg/kg (maximum dose 8 mg) dexamethasone
Additionally a single dose of 2 000 µg budesonide administered with a nebulizer
Racemic adrenaline¹ with a nebulizer
4-5 kg	0.2 ml (4.5 mg)
6-7 kg	0.3 ml (6.8 mg)
8-9 kg	0.4 ml (9.0 mg)
>10 kg	0.5 ml (11 mg)

¹ Racemic adrenaline is diluted with 2-3 ml isotonic (0.9%) NaCl solution. If racemic adrenaline is not available, adrenaline 1 mg/ml may be inhaled at a dose of 0.2-0.5 ml/kg up to 5 mg. Doses below 2 ml should be diluted as with racemic adrenaline.

Indications for referral to hospital

Assessment of respiratory distress and of the child's general condition (exhaustion from high respiratory effort) is essential when determining where a patient with laryngitis should be treated.
Hoarseness and barking cough can be treated at home.
Patients with any of the following conditions should be assessed in specialized care:
- deteriorated general condition
- inspiratory stridor continuing despite first-aid medication
- respiratory distress recurring during follow-up at emergency services (1-2 h) after receiving first-aid medication or
- reduced oxygen saturation (< 95%) during follow-up at the emergency service after first-aid medication.

References

Siebert JN, Salomon C, Taddeo I, et al. Outdoor Cold Air Versus Room Temperature Exposure for Croup Symptoms: A Randomized Controlled Trial. Pediatrics 2023;152(3): [PubMed]
Gates A, Gates M, Vandermeer B, et al. Glucocorticoids for croup in children. Cochrane Database Syst Rev 2018;8(8):CD001955 [PubMed]
Eghbali A, Sabbagh A, Bagheri B, et al. Efficacy of nebulized L-epinephrine for treatment of croup: a randomized, double-blind study. Fundam Clin Pharmacol 2016;30(1):70-5 [PubMed]
Bjornson C, Russell K, Vandermeer B, et al. Nebulized epinephrine for croup in children. Cochrane Database Syst Rev 2013;2013(10):CD006619 [PubMed]
Klassen TP, Watters LK, Feldman ME, et al. The efficacy of nebulized budesonide in dexamethasone-treated outpatients with croup. Pediatrics 1996;97(4):463-6 [PubMed]

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