Croup (laryngotracheitis and laryngotracheobronchitis)

Last updated: December 2023

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 a Citation a. Administer orally if possible in order to avoid causing agitation in the child as this may worsen symptoms.  PO: 0.15 to 0.6 mg/kg (max. 16 mg) 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: 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:
  • dexamethasone a Citation a. 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 child b Citation b. 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.