• All patients with croup should be given oral dexamethasone.

• Patients with moderate or severe symptoms should also be given nebulised adrenaline.

• Well children can be discharged home at 2-4hrs post nebulised adrenaline.

• Croup scores have no place in acute management – they are for research purposes only.

This is a controlled document. If you are using a printed copy, check it against the guidelines site to ensure you are using the latest edition.

Print copies must be destroyed after use.

Abbreviations

• Symptoms are a result of upper airway obstruction due to generalised inflammation of the airways, usually as a result of viral infections (most commonly parainfluenza virus type 1 and 3)

• Suspect croup in a child with sudden-onset, seal-like barking cough

• May be accompanied by stridor, intercostal or sternal recession, or tracheal tug

• Symptoms worse at night and increase with agitation

• Prodromal, non-specific upper respiratory tract symptoms (coryza, non-barking cough, mild fever) may be present within 12 to 48 hours

• Hoarse voice is also common

• Usual age group is 3 months to 6 years

• Most cases are self-limiting and symptoms resolve within 48 hours

• Signs of respiratory distress or failure occur in moderate to severe cases

Mild

• Seal-like barking cough

• No stridor or sternal / intercostal recession at rest

• Normal observations

Moderate

• Seal-like barking cough

• Stridor and sternal / intercostal recession at rest

• No agitation or lethargy

Severe

• Seal-like barking cough

• Stridor and sternal / intercostal recession at rest

• Agitation, lethargic

Impending respiratory failure

• Increasing upper airway obstruction

• Severe Respiratory Distress

• Asynchronous chest wall and abdominal movement

• Fatigue, pallor, cyanosis

• Decreased level of consciousness

• Tachycardia

• Death from croup is rare (1 in 30,000 cases)

• Mild croup: self-limiting without treatment but quicker resolution with dexamethasone

• Moderate croup: mostly resolves without significant complications

• Prognosis excellent with dexamethasone and nebulised adrenaline

• Severe upper airway obstruction can lead to respiratory failure and arrest

Bacterial tracheitis

• Fever, sudden onset stridor and respiratory distress.

• This usually follows a viral-like respiratory illness from which the person appears to be recovering but then suddenly becomes acutely worse.

Epiglottitis

• Sudden onset of high fever, dysphagia, drooling, anxiety, non-barking cough.

• Preferred posture is to sit upright with head extended. (Rare, mostly in unvaccinated children, due to Haemophilus influenzae B (HiB) – always check Immunisation status)

Foreign body in upper airway

• Sudden onset dyspnoea and stridor.

• Usually clear history of foreign body ingestion/ inhalation. No prodrome or symptoms of viral illness. No fever. Consider in <72hrs repeat attenders.

Retropharyngeal/ peritonsillar abscess

• Dysphagia, drooling, stridor, dyspnoea, tachypnoea, neck stiffness, unilateral cervical adenopathy.

• Onset is usually more gradual than croup and accompanied by fever.

Angioneurotic oedema

• Acute swelling in upper airway (face, tongue, pharynx) that may cause dyspnoea and stridor. Fever is uncommon. Occurs at any age.

Allergic reaction

• Rapid onset dysphagia, stridor, usually accompanied by urticarial rash. Occurs at any age. Usually known trigger.

See Management of Croup – Summary (above)

Lower threshold for hospital admission in children with

• Chronic lung disease

• Haemodynamically significant congenital heart disease (e.g., large VSD)

• Neuromuscular disorders

• Immunodeficiency

• Age under 3 months (consider alternative diagnosis)

• Inadequate fluid intake

• Longer distance to healthcare in case of deterioration

• Prior history of intubation

• Social concerns

Treatment with no added benefit

• Humidified air

• Antibiotics

• Beta-2 agonist

• Decongestants

• Heliox

1. National Institute for Health and Care Excellence [NICE] (2022) Croup. Available at: https://cks.nice.org.uk/topics/croup/ (Accessed: 09 November 2023).

2. Bjornson, C. and Johnson, D. (2023) 'Croup', in BMJ Best Practice. London: BMJ Best Practice. Available at: https://bestpractice.bmj.com/topics/en-gb/681 (Accessed: 09 November 2023).

3. Ortiz-Alvarez, O. (2017) 'Acute management of croup in the emergency department', Paediatrics and Child Health, 22(3), pp. 166-173. Available at: https://doi.org/10.1093/pch/pxx019 (Accessed: 09 November 2023).

4. Aregbesola, A. et al. (2023) 'Glucocorticoids for croup in children', Cochrane Database of Systematic Reviews, 1, CD001955. Available at: https://doi.org/10.1002/14651858.CD001955.pub5 (Accessed: 09 November 2023).

5. Cetinkaya, F., Tüfekçi, B. S. and Kutluk, G. (2004) 'A comparison of nebulized budesonide, and intramuscular, and oral dexamethasone for treatment of croup', International Journal of Pediatric Otorhinolaryngology, 68(4), pp. 453-456. Available at: https://doi.org/10.1016/j.ijporl.2003.11.017 (Accessed: 09 November 2023).

6. Bjornson, C. et al. (2013) 'Nebulized epinephrine for croup in children', Cochrane Database of Systematic Reviews, 10, CD006619. Available at: https://doi.org/10.1002/14651858.CD006619.pub3 (Accessed: 09 November 2023).

7. Lavine, E. and Scolnik, D. (2001) 'Lack of efficacy of humidification in the treatment of croup: Why do physicians persist in using an unproven modality?' Canadian Journal of Emergency Medicine, 3(3), pp. 209-212. Available at: https://doi.org/10.1017/s1481803500005571 (Accessed: 09 November 2023).

This guideline has been registered with the Trust. However, clinical guidelines are guidelines only. The interpretation and application of clinical guidelines will remain the responsibility of the individual clinician. If in doubt, contact a senior colleague or expert. Caution is advised when using guidelines after the review date.

This guideline is for use in Frimley Health NHS Foundation Trust hospitals only. Any use outside this location will not be supported by the Trust and will be at the risk of the individual using it.

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