Paediatrics

Croup

A usually viral upper-airway infection causing subglottic swelling and a barking cough, hoarse voice and inspiratory stridor; keep the child calm, give steroid treatment when indicated, and treat stridor at rest or deterioration as an airway emergency.

In a nutshell

Croup causes a barking cough, hoarseness and inspiratory stridor from viral subglottic swelling. Keep the child calm and upright, give a single steroid dose when indicated, use nebulised adrenaline for significant stridor or distress as a temporary bridge, and escalate immediately for cyanosis, exhaustion, drooling or severe breathing difficulty.

Classic presentation

A young child with a coryzal prodrome, barking cough, hoarse voice and inspiratory stridor, often worse overnight.

Key points

Stridor at rest and chest recession indicate more significant obstruction than a barking cough or stridor only when upset.
Keep the child calm on a carer's lap; distress and forced examination can worsen obstruction.
A common UK dexamethasone regimen is 0.15 mg/kg (see BNFc and local protocol) as a single dose when clinically indicated.
Nebulised adrenaline is temporary relief for significant or worsening obstruction; verify the preparation and dose in the local paediatric protocol and observe for recurrent symptoms.
Drooling, dysphagia, a toxic appearance or a child sitting forward suggests epiglottitis or another dangerous airway diagnosis: do not force throat examination.
Steam inhalation and sedating cough medicines are not appropriate.
Discharge requires comfortable breathing, adequate intake, a secure diagnosis and explicit 999 safety-netting.

First-line investigation

None routinely: croup is a clinical diagnosis assessed without distressing the child.

Management

Minimise distress and recognise the airway emergency

Keep the child upright and with the carer; call senior paediatric, anaesthetic and ENT help early for stridor at rest with severe distress, cyanosis, exhaustion or diagnostic concern.^4,2,3

Treat the inflammation

Give a single dexamethasone dose according to the current BNFc and local protocol; use the local alternative if oral treatment is not possible.^1,5,7,6

Bridge significant obstruction

Give nebulised adrenaline for significant stridor at rest or worsening obstruction and observe for recurrent symptoms; verify the preparation and dose against the BNFc and local guideline.^5,3

Exclude dangerous alternatives and secure the airway

Treat drooling, dysphagia, toxicity, sudden choking onset, cyanosis, exhaustion or non-response as a senior airway emergency; do not force throat examination and involve anaesthetics and ENT.^4,2,3

Discharge only with a safe plan

Discharge only when breathing is comfortable, oral intake is adequate and carers have clear red flags and immediate-help instructions; avoid steam and sedating cough medicines.^2,3

Exam traps

Normal oxygen saturation does not exclude significant upper-airway obstruction; hypoxia is late.
Stridor at rest is not mild croup.
Nebulised adrenaline is a bridge, not definitive treatment; monitor for recurrence after its temporary effect wears off.
Drooling and toxic appearance are not routine croup: avoid throat examination and involve anaesthetics and ENT urgently.
Do not use steam inhalation.

Illustrations

Subglottic narrowing cross-sectionDiagram comparing a normal subglottic airway to one narrowed by mucosal oedema within the fixed cricoid ring.PassFinals · original

Steeple sign in croupAnteroposterior neck radiograph showing smooth, symmetric subglottic tracheal tapering, marked by the arrow, producing the steeple sign of croup.Frank Gaillard, Wikimedia Commons · CC-BY-SA-3.0

Key sources

This page is exam revision material, not medical advice, and must not be used for patient care. Always check drug doses against the BNF and current guidance. Full disclaimer.