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TarjaHeiskanen-Kosma

Laryngitis in Children

Essentials

  • Laryngitis is a common infection in small children. Most commonly it occurs in children aged 6 to 36 months.
  • Most patients only have mild symptoms and can be treated at home.
  • The disease resolves spontaneously. In the treatment of typical laryngitis, antimicrobial drugs, bronchodilator drugs, antihistamines or cough medicines are of no benefit.
  • Patients with troublesome symptoms are treated with glucocorticoids on an outpatient emergency unit. When necessary, racemic adrenaline with nebulizer may be also be given as first aid.
  • Monitoring in a hospital is warranted in patients with http://www.dynamed.com/condition/croup#TREATMENT_SETTING
    • clear inspiratory stridor and retraction on inspiration also in an upright position and at rest despite first aid medication
    • symptom recurrence during follow-up (1-2 hours) after administration of the first aid medication
    • even a mild disturbance in oxygenation after first aid medication
    • suspected bacterial tracheitis, pneumonia complicating laryngitis, or some other severe infection.

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.

History and clinical findings

  • Issues to be considered in the diagnostics are presented in table T2.
  • The symptoms of laryngitis include sudden-onset dry, hoarse, dull, ”barking” cough, inspiratory wheezing in association with crying, and noisy, difficult inspiration (stridor).
  • Try to observe the degree of breathing difficulty and chest wall motions when the child is calm and not crying. The best moment may be in the beginning of the consultation before the child starts to ”cry for seeing a white coat”.
  • 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 threatening respiratory failure (ventilation disturbance).
  • In order to recognize retractions of intercostal spaces and/or jugular fossa the child should be sufficiently undressed.
  • In patients with recurring laryngitis, the severity of earlier episodes may predict the severity of the present episode.
  • A bacterial infection (pneumonia, bacterial tracheitis, epiglottitis) should be suspected if fever remains high, the general condition deteriorates and there is no response to the administered medication http://www.dynamed.com/condition/croup#DIFFERENTIAL_DIAGNOSIS.
  • Emergency laboratory tests or x-rays are not needed in uncomplicated laryngitis.

Issues to be noted in the diagnostics of laryngitis in children

Clinical featureFurther detailsTo be noted
Atypical ageLess than 6 (12) monthsPossible structural or functional abnormality of the larynx
Atypical clinical pictureNo cough, severe clinical picturePossible epiglottitis
Inspiratory stridorStridor at rest (when the child is not crying)Requires drug treatment and monitoring at hospital
Oxygen saturation less than 95%Hypoxia in association with inspiratory difficulty suggests a risk of respiratory failure.Requires supplemental oxygen, drug treatment and monitoring at hospital
Source: Korppi M et al. Duodecim 2015;131:157-61.
Treatment Glucocorticoids for Acute Laryngotracheitis in Children, Nebulised Adrenaline for Croup in Children, Humidified Air Inhalation for Viral Croup
  • Typical laryngitis resolves spontaneously.
  • Cool, moist air is beneficial as first-aid: the child should be taken in an upright position, carried by one of the parents, to an open window or outdoors http://www.dynamed.com/condition/croup#OTHER_MANAGEMENT.
  • There is no scientific evidence on the efficacy of vapour breathing.
  • Glucocorticoids http://www.dynamed.com/condition/croup#CORTICOSTEROID provide symptomatic relief in laryngitis.
    • Dexamethasone 0.15-0.6 mg/kg orally or intramuscularly (maximum dose 16 mg). The effect starts slowly.
    • Betamethasone 0.25-0.4 mg/kg orally (maximum dose 7 mg). A 0.5 mg tablet dissolved in liquid tastes better than dexamethasone.
    • Inhaled budesonide can be administered as additional medication if needed, the maximum dose being 2 mg.
    • If other preparations are not available, also prednisolone 1-2 mg/kg (maximum dose 40 mg) may be given orally. Children, however, easily vomit it up.
  • In severe inspiratory difficulty, racemic adrenaline (0.5-1.0 mg/kg) can be given over 5-10 minutes with a nebulizerhttp://www.dynamed.com/condition/croup#NEBULIZED_EPINEPHRINE; see table T1.
    • If racemic adrenaline is not available, adrenaline 1 mg/ml may be used. Its dose is in milligrams half of the dose of racemic adrenaline: 2.3 ml for children weighing under 10 kg, 3.4 ml for children weighing 10-20 kg and 4.5 ml for children weighing over 20 kg.
    • Because the respiratory difficulty often recurs after 1-2 hours, these children should be referred to hospital after first aid or followed up at the office for long enough.

Dosage of racemic adrenaline (22.5 mg/ml) to be administered with a nebulizer1) to treat laryngitis in children

Weight of childS2 Racepinephrine Inhalation Solution USP 2.25 % (diluted1 )
≤ 5 kg0.2 ml (4.5 mg)
6-7 kg0.3 ml (6.8 mg)
8-9 kg0.4 ml (9.0 mg)
≥ 10 kg0.5 ml (11 mg)
1) Racemic adrenaline is administered at the doses presented in the table; the indicated dose is further diluted in 2-3 ml of 0.9 % saline solution before inhalation with a nebulizer.

Indications for referral to hospital

  • The severity of the breathing difficulty and assessment of the general condition (exhaustion) determine where the child is managed.
    • Most patients have a mild disease; only about 1% have severe laryngitis with breathing difficulty.
  • Hoarseness and laryngeal cough can be treated at home.
  • Inspiratory wheezing while the child is calm and at rest is a significant finding and suggests severe laryngitis.
  • About 50% of children with marked retraction of the intercostal spaces and/or the jugular fossa and with use of auxiliary respiratory muscles get worse. A small proportion of them need intensive care. These children should be referred to hospital after first aid.
  • A clearly ill, feverish child with a prolonged laryngitis should be referred as a suspected case of bacterial tracheitis.

Evidence Summaries ⬆