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The adverse effects of corticosteroids in pediatric patients are similar to those in adults (see ADVERSE REACTIONS ). Like adults, pediatric patients should be carefully observed with frequent measurements of blood pressure, weight, height, intraocular pressure, and clinical evaluation for the presence of infection, psychosocial disturbances, thromboembolism, peptic ulcers, cataracts, and osteoporosis. Pediatric patients who are treated with corticosteroids by any route, including systemically administered corticosteroids, may experience a decrease in their growth velocity. This negative impact of corticosteroids on growth has been observed at low systemic doses and in the absence of laboratory evidence of HPA axis suppression (., cosyntropen stimulation and basal cortisol plasma levels). Growth velocity may therefore be a more sensitive indicator of systemic corticosteroid exposure in pediatric patients treated with corticosteroids should be monitored, and the potential growth effects of prolonged treatment should be weighed against clinical benefits obtained and the availability of treatment alternatives. In order to minimize the potential growth effects of corticosteroids, pediatric patients should be titrated to the lowest effective dose.
Figure 1 is an algorithm for outpatient management of croup based on illness severity. 25 – 34 Keeping a symptomatic child calm by avoiding distressing procedures is important because agitation may worsen airway obstruction. Positioning the child so that he or she is comfortable is appropriate because no particular position has been shown to be more beneficial in the assessment. Oxygen should be administered when the child is hypoxic or in severe respiratory distress. Heliox, a helium-oxygen mixture, has been used to reduce airflow resistance and turbulence. Although case reports have been encouraging, a systematic review found insufficient evidence that heliox is beneficial for croup. 35 Likewise, studies do not support the routine use of exposure to cold air, antipyretics, analgesics, antitussives, decongestants, or prophylactic antibiotics.