Recurrent Croup

Croup is a respiratory illness that specifically affects the upper-most part of the trachea, which is already the narrowest area of a young child’s airway. Symptoms usually consist of stridor, a barky cough, and fever. It can vary from mild to severe, but when severe, it can cause significant distress to the child and their family given the degree of difficulty breathing, and lead to emergency room visits, hospital stays, and steroid treatments. A variety of respiratory viruses can lead to croup, the most common being parainfluenza virus. Symptoms tend to resolve within two days but can last up to a week. 

Croup can occur most expectedly between the ages of 6 months and 4 years. During the evaluation of these patients by the pediatrician, the following contributors to airway irritation or swelling can be explored and treated: 

• Exposure to second-hand smoke
• Gastroesophageal reflux disease: if typical symptoms or a strong suspicion are present, consider conservative management and/or a trial of medical therapy. 
• Atopic airway disease such as asthma
• Postnasal drip: for patients with nasal congestion, chronic cough, sinus issues or a frequent runny nose, consider a 2-3 month trial of medical management with nasal saline spray and topical steroid spray, as well as allergy work/up and treatment. 

In some patients, a more detailed airway evaluation may be recommended. This could involve a laryngoscopy either awake in clinic or sedated in the operating room, depending on symptoms and level of suspicion. Risk factors that should prompt consideration of a referral to an Otolaryngology clinic include the following: 

• Recurrent and severe episodes, especially > 3 per year
• Recurrent “croup” symptoms starting prior to 1 year of age. 
• Recurrent croup continuing over 4 years of age. 
• History of intubation
• Croup symptoms such as stridor, hoarseness, shortness of breath, in between acute episodes
• Recurrent croup in addition to symptoms of chronic aspiration, such as frequent coughing when drinking thin liquids. Chronic microaspiration can lead to airway irritation and swelling, and a predisposition for croup-like symptoms. 

Other considerations at the same time as a referral to Otolaryngology: 

• If there is severe GERD that has resulted difficult to treat, or suspicion for Eosinophilic esophagitis (EoE), then a referral to Pediatric Gastroenterology can also be considered. 
• A referral to Pediatric Pulmonology can be discussed if the patient has severe chronic respiratory issues including asthma that is difficult to control. 
• If there are concerns for coughing on thin liquids or other types of dysphagia, a referral to the Speech and Language Pathology-Feeding clinic should be considered, where a modified barium swallow study could be done to evaluate the patient’s swallowing mechanism. 

Sources:

Quraishi H, Lee DJ. Recurrent Croup. Pediatr Clin North Am. 2022 Apr;69(2):319-328. 

Vu JP, Jagannath D, Spielberg DR, Chiou EH, Hosek KE, Lambert EM. Triple endoscopy and recurrent croup in children: A single aerodigestive center experience. Auris Nasus Larynx. 2024 Feb;51(1):125-131. 

Tongue tie in infants

Tongue tie, or ankyloglossia, consists of having a tongue with limited mobility in any direction (upward, to the sides, outward) due to a shortened tongue frenulum. There has been an uptick in the diagnosis and treatment of this condition in recent years, and in many cases the benefit and indication of a procedure are still controversial. 

The strongest evidence for diagnosing and treating ankyloglossia lies in the infancy age. Breastfeeding can be challenging, and there are occasions where a short tongue frenulum can contribute to these difficulties. If no other factors have been identified and there are significant issues with latching, maintaining a latch, suctioning milk efficiently, or maternal discomfort, a tongue tie release can be beneficial. This is especially true if the child is losing or unable to gain weight and failing to thrive. In this case an urgent referral to our clinic is appropriate and recommended. In infancy, the procedure can be performed in clinic without sedation and is generally well tolerated and low risk. Some of the rare risks include bleeding, scarring with need for a repeat procedure, failure to improve, infection, oral aversion, and injury to surrounding salivary glands.  

It is important to perform a full history and examination however, prior to concluding that a tongue tie is the main contributor. Other factors can also affect feeding in infants, including:

• Discoordination, such as may occur in premature infants
• Tendency to aspirate
• Underlying neurologic issues 
• Anatomical issues such as a smaller jaw, nasal obstruction, an abnormal palate or large tongue. 

If any of these issues are identified by the pediatrician, additional referrals may be made (such as to a pediatric feeding clinic led by a speech and language pathology expert, a craniofacial team, or a pediatric neurologist). It is also essential that a lactation consultant be following the infant prior to a lingual frenotomy. A tongue tie release is NOT recommended to prevent a future feeding or speech disorder. 

Once the child reaches 9 months of age, a procedure may require sedation and general anesthesia. In older children who did not have feeding issues, the indications for a tongue tie release are more controversial. In some cases, the clarity of speech and articulation may be affected, but an appropriate period of speech therapy is always recommended prior to any tongue-related surgical intervention for speech. 

Older children may desire a tongue tie release for social reasons, such as to be able to “lick an ice cream cone”. In many of these cases, the procedure can be done in clinic with local anesthesia.

Upper lip frenulum

An upper lip frenulum is a normal structure in an infant. There is a lack of convincing evidence that an upper lip tie affects feeding or breastfeeding in a significant way in infants, and therefore releasing an upper lip tie is controversial. There is a high chance that it is unlikely to provide any benefit. It is generally accepted that upper lip frenotomy in infants or children with primary dentition will not prevent the occurrence of an upper incisor diastema (space between the upper teeth). 

Source: Messner AH, Walsh J, Rosenfeld RM, Schwartz SR, Ishman SL, Baldassari C, Brietzke SE, Darrow DH, Goldstein N, Levi J, Meyer AK, Parikh S, Simons JP, Wohl DL, Lambie E, Satterfield L. Clinical Consensus Statement: Ankyloglossia in Children. Otolaryngol Head Neck Surg. 2020 May;162(5):597-611. 

Recurring or chronic ear infections

Ear infections can have a significant influence on a child’s and their family’s quality of life. Many children may have occasional ear infections, usually associated with colds and upper respiratory infections. Most of them will resolve on their own if mild, or with antibiotics. However, there are instances when a patient should be referred to an Otolaryngologist for further evaluation or treatment. This includes the following: 

• Three infections within 6 months with significant symptoms and requiring antibiotics, or 4 infections within 12 months. 
• Fluid that has not gone away after 3 months, especially if causing recurring pain, hearing loss, balance problems, or speech delay. If it has not been 3 months and the fluid is asymptomatic, watchful waiting is generally deemed safe. Fluid is less likely to go away if it is found during a regular check/up and if the date when it first started is unknown. 

For persisting middle ear issues in children, there are some measures that can help: 

~ Avoiding exposure to second-hand smoke. 

~ Weaning the child off a pacifier if they are still using one, especially if they are over 12 months of age and during the day. Of note, prolonged use of pacifier can cause longer term issues such as abnormal teeth and an abnormal bite.

~ Medications have not been proven to help in the setting of chronic middle ear fluid. This includes decongestants, antihistamines, nasal topical steroid sprays, or antibiotics. If any of these therapies are indicated for another reason such as severe nasal congestion or mouth breathing, they can be recommended, but there is no evidence that they help resolve middle ear problems. 

~ In the context of hearing loss that is suspected to be due to fluid in children, some recommendations can be made to parents during the “watch and wait” period (source: Published Clinical Practice Guideline: Otitis Media with Effusion, 2016): 

• Get the child’s attention before speaking and when possible, speak within 3 feet of the child. 
• Turn off background sounds such as from a television. 
• Face the child and speak clearly, using gestures such as hands or pictures in addition to speech. 
• Use short, simple sentences and speak slower, raising the sound level. 
• Read to or with the child, and call attention to sounds and spelling of words when reading. 
• Patiently repeat words or phrases if misunderstood. 
• At school, ask for accommodations such as sitting closer to the teacher. The school may be able to provide a personal microphone or a sound field amplification system. 

Source: Rosenfeld RM, Shin JJ, Schwartz SR, et al. Clinical Practice Guideline: Otitis Media with Effusion Executive Summary (Update): Otitis Media with Effusion Executive Summary (Update). Otolaryngology–Head and Neck Surgery. 2016;154(2):201-214.