Croup (laryngotracheitis and laryngotracheobronchitis)

Last updated: October 2024

Common viral respiratory infection with peak incidence amongst children between 6 months and 3 years.

Clinical features

• Typical barking cough, hoarse voice or cry.
• Inspiratory stridor (abnormal high pitched sound on inspiration):
  • Croup is considered mild if the stridor only occurs with agitation;
  • Croup is considered severe if there is stridor at rest, especially when it is accompanied by respiratory distress.
• Wheezing may also be present if the bronchi are involved.

Treatment

• In the absence of inspiratory stridor or intercostal, subcostal or sternal retractions, treat symptomatically: ensure adequate hydration, seek medical attention if symptoms worsen (e.g. respiratory difficulty, noisy breathing, inability to tolerate oral fluids).

• If stridor is only present with agitation (mild croup)[1]Citation 1.Pocket book of primary health care for children and adolescents: guidelines for health promotion, disease prevention and management from the newborn period to adolescence. Copenhagen: WHO Regional Office for Europe; 2022. Licence: CC BY-NCSA 3.0 IGO.
  https://www.who.int/europe/publications/i/item/9789289057622:
  • Assure adequate hydration.
  • Corticosteroids:
    • dexamethasone PO: 0.15 to 0.6 mg/kg (max. 16 mg)aCitation a.If children can easily return to hospital in case of deterioration or return of symptoms, administer 0.15 mg/kg of dexamethasone. Otherwise, the dose of 0.6 mg/kg should be used. single dose
    • or, if not available, prednisolone PO: 1 mg/kg single dose
  • Keep the child under observation at least 30 minutes after oral corticosteroid. Consider hospitalisation or longer observation (> 4 hours) if the child is less than 6 months old, or is dehydrated, or lives far from health facility.

• If danger signs are present (stridor at rest, respiratory distress, hypoxia) or the child is unable to drink, admit to hospital[1]Citation 1.Pocket book of primary health care for children and adolescents: guidelines for health promotion, disease prevention and management from the newborn period to adolescence. Copenhagen: WHO Regional Office for Europe; 2022. Licence: CC BY-NCSA 3.0 IGO.
  https://www.who.int/europe/publications/i/item/9789289057622:
  • Administer oxygen continuously if respiratory distress or SpO₂ < 92%: maintain SpO₂ between 94 and 98% (or if SpO₂ cannot be determined, at least 5 litres/minute).
  • Insert a peripheral IV line and provide IV hydration.
  • Epinephrine (adrenaline) via nebulizer[2]Citation 2.Bjornson C, Russell K, Vandermeer B, Klassen TP, Johnson DW. Nebulized epinephrine for croup in children. Cochrane Acute Respiratory Infections Group, ed. Cochrane Database Syst Rev. Published online October 10, 2013.
    https://doi.org/10.1002/14651858.CD006619.pub3 , bCitation b.Although not licensed for this indication, epinephrine 1:1000 (1 mg/ml) should be used for nebulisation.: 0.5 mg/kg (max. 5 mg) to be repeated every 20 minutes if danger signs persist (see table below).
    Monitor heart rate during nebulization (if heart rate greater than 200, stop the nebulization).

• Corticosteroids:

  • dexamethasonecCitation c.Administer orally if possible in order to avoid causing agitation in the child as this may worsen symptoms. PO (or IM or IV if the child is vomiting): 0.6 mg/kg (max. 16 mg) single dose (see table below)

  • or, if not available, prednisolone PO: 1 mg/kg single dose

• Suspect bacterial tracheitis in a critically ill appearing childdCitation d.Critically ill appearing child: weak grunting or crying, drowsiness, difficult to arouse, does not smile, disconjugate or anxious gaze, pallor or cyanosis, general hypotonia.with croup who does not improve with the above treatment.

• If the patient has a complete airway obstruction, intubation if possible or emergency tracheotomy.