COVID-19 is Observed in Older Children During the Omicron Wave in New York City.

BACKGROUND: The Omicron variant of SARS-CoV-2 has a predilection for the upper airways, causing symptoms such as sore throat, hoarse voice, and stridor. OBJECTIVE: We describe a series of children with COVID-19-associated croup in an urban multicenter hospital system. METHODS: We conducted a cross-sectional study of children ≤18 years of age presenting to the emergency department during the COVID-19 pandemic. Data were extracted from an institutional data repository comprised of all patients who were tested for SARS-CoV-2. We included patients with a croup diagnosis by International Classification of Diseases, 10th revision code and a positive SARS-CoV-2 test within 3 days of presentation. We compared demographics, clinical characteristics, and outcomes for patients presenting during a pre-Omicron period (March 1, 2020-December 1, 2021) to the Omicron wave (December 2, 2021-February 15, 2022). RESULTS: We identified 67 children with croup, 10 (15%) pre-Omicron and 57 (85%) during the Omicron wave. The prevalence of croup among SARS-CoV-2-positive children increased by a factor of 5.8 (95% confidence interval 3.0-11.4) during the Omicron wave compared to prior. More patients were ≥6 years of age in the Omicron wave than prior (19% vs. 0%). The majority were not hospitalized (77%). More patients ≥6 years of age received epinephrine therapy for croup during the Omicron wave (73% vs. 35%). Most patients ≥6 years of age had no croup history (64%) and only 45% were vaccinated against SARS-CoV-2. CONCLUSION: Croup was prevalent during the Omicron wave, atypically affecting patients ≥6 years of age. COVID-19-associated croup should be added to the differential diagnosis of children with stridor, regardless of age. © 2022 Elsevier Inc.

Case Report: A 29-Year-Old Pregnant Woman at 24 Weeks of Gestation Presenting with Laryngotracheitis and COVID-19 Due to the R.1 Variant of SARS-CoV-2.

BACKGROUND Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) was discovered in December 2019 in Wuhan, China. Coronavirus disease (COVID-19) mainly presents with lower respiratory tract symptoms. On the other hand, laryngotracheitis or croup shows barky cough and it is rare in adults. There were no reports of laryngotracheitis with COVID-19 in pregnant women. We report the case of a pregnant woman at 24 weeks of gestation presenting with acute laryngotracheitis and COVID-19 due to the R.1 variant of SARS-CoV-2. CASE REPORT A 29-year-old previously healthy woman at 24 weeks of gestation presented with hoarseness and sore throat without fever, of 1-day duration. Although she was treated by her primary care physician with nebulized epinephrine, her symptoms did not resolve. She came to our hospital the same day. On arrival at our department, she was tachypneic and had a 95% oxygen saturation. She had stridor and barking cough. Laryngeal endoscopy revealed edema under the vocal cords. She was hospitalized urgently. SARS-CoV-2 polymerase chain reaction (PCR) testing was positive and the E484K mutation was confirmed. She was treated with oral and inhaled corticosteroids. Two days after admission, her symptoms were improved. She was discharged 10 days after admission. Edema under the vocal cords was completely improved 24 days after discharge. There were no adverse effects on the pregnancy. CONCLUSIONS COVID-19 laryngotracheitis has a more severe disease course than other causes, especially in pregnancy. COVID-19 laryngotracheitis should be use corticosteroids to treatment. Prednisolone is recommended for laryngotracheitis with COVID-19 during pregnancy.

Use of a Clinical Guideline and Orderset to Reduce Hospital Admissions for Croup.

BACKGROUND: Studies have found infrequent interventions after croup admission. Our objectives were to achieve 25% reduction in (1) admission rate and (2) neck radiograph utilization among patients presenting to the emergency department. METHODS: At our tertiary children's hospital, we implemented clustered interventions including education, guideline, and orderset integration. We included patients 3 months to 8 years old with an emergency department, observation, or inpatient encounter for croup. We excluded patients with direct or ICU admissions, complex chronic conditions, or concurrent asthma, pneumonia, or bronchiolitis. We reviewed a random sample of 60% of encounters from baseline (October 1, 2017 to September 30, 2019) and implementation (October 1, 2019 to September 30, 2020) periods. We conducted a posthoc analysis from October 1, 2017 to December 1, 2021 to assess sustainment during coronavirus disease 2019. Interrupted time series analysis was used to evaluate changes in outcome, process, and balancing measures. RESULTS: There were 2906 (2123 baseline and 783 implementation) encounters included. Extrapolating preintervention trend estimates, the baseline admission rate of 8.7% decreased to 5.5% postintervention (relative decrease 37% [95% confidence interval: 8 to 66]) and sustained over 26 months after implementation. Admission rate in patients receiving 2 or fewer racemic epinephrine was significantly lower in implementation (1.7%) compared with baseline (6.3%), relative decrease of 72% (95% confidence interval: 68 to 88). There were no significant changes in neck radiographs, length of stay, or revisits. CONCLUSIONS: Croup quality improvement interventions were associated with a significant decrease in hospital admissions with no increase in revisits.

Clinical characteristics of pediatric patients with COVID-19 between Omicron era vs. pre-Omicron era.

INTRODUCTION: Detailed data on clinical characteristics in children with the omicron strain of SARS-COV-2 are limited. METHODS: We conducted a retrospective observational study of children with COVID-19 at the National Center for Child Health and Development to evaluate the clinical manifestations during and before the emergence of the omicron variant. Only symptomatic patients without underlying diseases were included. Participants were divided into two temporal groups: the "omicron era" (1/2022-2/2022) and the "pre-omicron era," where the delta variant predominated (7/2021-11/2021). The patients were subclassified into an older vaccine-eligible group (aged 12-17 years), a younger vaccine-eligible group (aged 5-11 years), and a vaccine-ineligible group (aged 0-4 years). RESULTS: We compared 113 patients in the omicron era with 106 in the pre-omicron era. Most patients in both eras had non-severe disease, and no patients required mechanical ventilation or died. Among patients aged 0-4 years, sore throat and hoarseness were more common during the omicron era than the pre-omicron era (11.1% vs. 0.0% and 11.1% vs. 1.5%, respectively). Croup syndrome was diagnosed in all patients with hoarseness. Among patients aged 5-11 years, vomiting was more frequent during the omicron era (47.2%) than during the pre-omicron era (21.7%). Cough and rhinorrhea were less common during the omicron era in patients aged 0-4 and 5-11 years, respectively, than during the pre-omicron era. CONCLUSIONS: In children with COVID-19, clinical manifestations differed between the omicron and pre-omicron eras. In the Omicron era, croup syndrome was more frequent in vaccine-ineligible children.

Croup during the Coronavirus Disease 2019 Omicron Variant Surge.

We conducted a retrospective review of medical records of patients with croup seen during the coronavirus disease 2019 pandemic. Approximately 50% underwent testing for severe acute respiratory syndrome coronavirus 2. During the Delta wave, 2.8% of those tested were positive for severe acute respiratory syndrome coronavirus 2; this increased to 48.2% during the Omicron wave, demonstrating a strong correlation between the Omicron variant and croup.

Two Case Reports of Life-Threatening Croup Caused by the SARS-CoV-2 Omicron BA.2 Variant in Pediatric Patients.

Croup is a common upper airway infection characterized by a barking cough, stridor, and hoarseness. It is usually caused by viral infection. A small number of croup caused by coronavirus disease 2019 (COVID-19) has been reported in children before the omicron variant surge. Previously reported cases indicated that croup caused by COVID-19 can be treated in the same manner as those with other viral causes. We describe two cases (9-month-old girl and 11-month-old boy) of previously healthy infants who presented with a barking cough and chest retraction and required endotracheal intubation and cardiopulmonary resuscitation. Despite receiving dexamethasone and nebulized racemic epinephrine (NRE) treatment for croup in the emergency department, these patients still developed acute respiratory failure. Reverse transcription polymerase chain reaction (RT-PCR) of nasopharyngeal samples revealed severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) omicron BA.2 variant (Stealth omicron) and no other common respiratory viral pathogens. Both patients were treated with mechanical ventilation, dexamethasone, and NRE in the pediatric intensive care unit. The duration of intubation was 112 hours and 80 hours, respectively. Both patients were discharged without complications. To the best of our knowledge, this is the first report of life-threatening croup produced by the omicron BA.2 variant and confirmed by RT-PCR. We suggest that this SARS-CoV-2 variant may cause severe croup that may not improve with conventional treatment, even in children without underlying diseases.

Croup as a Manifestation of SARS-CoV-2 Omicron Variant Infection in Young Children.

Croup is an acute upper respiratory disease primarily caused by the parainfluenza virus. Owing to inflammation and edema of the upper airways, children present with barky cough and stridor, and some may experience respiratory distress. We investigated children aged < 5 years with coronavirus disease 2019 (COVID-19) admitted to two hospitals in Seoul, South Korea, and observed a spike in croup cases during the omicron surge. Among the 569 children admitted from March 1, 2021 to February 25, 2022, 21 children (3.7%) had croup, and the proportion of croup cases was significantly higher during the omicron wave than that during the delta wave (12.4% vs. 1.2%, P < 0.001). With the immediate administration of corticosteroids and epinephrine via nebulizer, the symptoms improved rapidly. During the current omicron surge, careful monitoring of the symptoms of croup in young children is needed for the diagnosis of COVID-19 and its timely management.

Croup Associated With SARS-CoV-2: Pediatric Laryngotracheitis During the Omicron Surge.

In this retrospective analysis, we describe weekly croup and corresponding viral prevalence patterns in a pediatric quaternary care system in metropolitan Atlanta. We characterize a series of 24 patients with croup associated with SARS-CoV-2 infection and show that this clinical presentation increased substantially in frequency during the period of high Omicron vs Delta transmission.

Croup as a Previously Unrecognized Symptom of COVID-19 in Infants.

Although the most common symptoms of coronavirus disease 2019 (COVID-19) in children are fever and cough, cases of croup associated with COVID-19 are reported in the literature and have increased sharply with the Omicron variant. We present severe acute respiratory syndrome coronavirus 2 as a viral agent in an infant presenting with croup.

Croup and COVID-19 in a child: a case report and literature review.

Croup (laryngotracheitis) is frequently encountered in the emergency department in a young child presenting with stridor. We describe a rare case of croup secondary to SARS-CoV-2 in an 18-month-old child who presented with stridor and respiratory distress and required urgent intubation. Subsequently, the child developed multisystem inflammatory syndrome in children (MIS-C). The child was monitored in paediatric intensive care unit. We would like to highlight that COVID-19 croup in children may be an indicator for MIS-C, and close monitoring is warranted as MIS-C is a life-threatening condition. Our limited experience suggests that COVID-19 croup especially if associated with MIS-C has an underlying more severe pathology and may require prolonged treatment in comparison with the typical croup or even COVID-19 croup. It is important to recognise this clinical entity during a time when most countries are in a third wave of COVID-19 pandemic.

Pediatric croup with COVID-19.

We describe three previously healthy children, admitted from our emergency department (ED) to our free-standing children's hospital, as the first documented cases of croup as a manifestation of SARS-CoV-2 infection. All three cases (ages 11 months, 2 years, and 9 years old) presented with non-specific upper-respiratory-tract symptoms that developed into a barky cough with associated stridor at rest and respiratory distress. All were diagnosed with SARS-CoV-2 by polymerase chain reaction testing from nasopharyngeal samples that were negative for all other pathogens including the most common etiologies for croup. Each received multiple (≥3) doses of nebulized racemic epinephrine with minimal to no improvement shortly after medication. All had a prolonged period of time from ED presentation until the resolution of their stridor at rest (13, 19, and 21 h). All received dexamethasone early in their ED treatment and all were admitted. All three received at least one additional dose of dexamethasone, an atypical treatment occurrence in our hospital, due to each patient's prolonged duration of symptoms. One child required heliox therapy and admission to intensive care. All patients were eventually discharged. Pathogen testing is usually not indicated in croup, but with "COVID-19 croup," SARS-CoV-2 testing should be considered given the prognostic significance and prolonged quarantine implications. Our limited experience with this newly described COVID-19 croup condition suggests that cases can present with significant pathology and might not improve as rapidly as those with typical croup.