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Croup

NICE CKS Croup. Last revised: May 2022. NICE BNF Treatment summaries. Croup

Background Information

Most commonly cause: parainfluenza

  • 6 months - 3 y/o
  • Male
  • Previous intubation

  • Initial prodromal phase
  • Followed by a sudden onset of: 
    • Seal-like barking cough - characteristic feature
    • Stridor
    • Hoarseness
    • Dyspnoea

 

Symptoms typically worsen or manifest at night and increase with agitation.

When examining a child with croup:

  • Do not frighten the children
  • Ensure the child is seated comfortably in the parent / carer's lap
  • Do not attempt to reposition the child (as the naturally adopted position minimises airway obstruction)


If epiglottitis is suspected, do NOT examine the oropharynx as it may precipitate further airway obstruction.

Severity Features
Mild
  • Only seal-like barking cough
  • Nothing else
Moderate
  • Seal-like barking cough
  • Stridor and sternal recession at rest
  • No / little agitation or lethargy
Severe
  • Seal-like barking cough
  • Stridor and sternal / intercostal recession
  • Agitation or lethargy
Impending respiratory failure
  • Minimal barking cough and stridor
  • Asynchronous chest wall and abdominal movement
  • Fatigue
  • Pallor
  • Cyanosis
  • Decreased level of consciousness
  • Tachycardia
  • Respiratory rate >70 / min
 

Diagnosis Guidelines

Croup is diagnosed clinically (see above for clinical features).

 

The characteristic X-ray finding is the steeple sign. Note that the steeple sign is NOT specific to croup, but simply indicative of subglottic narrowing (other causes include epiglottitis, tracheitis)

Clinically, investigations are not routinely performed but this is important for exams.

Management Guidelines

Admit all children apart from mild croup (i.e. only seal-like barking cough with nothing else).

Consider hospital admission if:
  • Respiratory rate >60 / min
  • High fever
  • 'Toxic' appearance
  • Mild croup with risk factors (chronic lung disease / haemodynamically significant congenital heart disease / neuromuscular disorders / immunodeficiency / <3 months / inadequate fluid intake / long-distance to healthcare)

Give single dose of oral dexamethasone (0.15 mg/kg) to be taken immediately to ALL patients (all severity)
  • If the child is too ill to take oral medication → nebulised budesonide / IM dexamethasone

In severe croup / impending respiratory failure:
  • Give controlled supplementary oxygen
  • If not controlled with corticosteroid → nebulised adrenaline 

References

Author: Adams Lau
Reviewer:
Last edited: 25/08/25